Circulating rna signatures specific to preeclampsia

ABSTRACT

The present invention includes methods and materials for use in the detection preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method including identifying in a biosample obtained from the pregnant women a plurality of circulating RNA (C-RNA) molecules.

CONTINUING APPLICATION DATA

This application claims the benefit of U.S. Provisional Application Ser. No. 62/939,324, filed Nov. 22, 2019, which is incorporated by reference herein.

FIELD OF INVENTION

The present invention relates generally to methods and materials for use in the detection and early risk assessment for the pregnancy complication preeclampsia.

BACKGROUND

Preeclampsia is a condition that occurs only during pregnancy, affecting 5% to 8% of all pregnancies. It is the direct cause of 10%-15% of maternal deaths and 40% of fetal deaths. The three main symptoms of preeclampsia may include high blood pressure, swelling of hands and feet, and excess protein in the urine (proteinuria), occurring after week 20 of pregnancy. Other signs and symptoms of preeclampsia may include severe headaches, changes in vision (including temporary loss of vision, blurred vision or light sensitivity), nausea or vomiting, decreased urine output, decreased platelets levels (thrombocytopenia), impaired liver function, and shortness of breath, caused by fluid in the lung.

The more severe the preeclampsia and the earlier it occurs in pregnancy, the greater the risks for mother and baby. Preeclampsia may require induced labor and delivery or delivery by cesarean delivery. Left untreated, preeclampsia can lead to serious, even fatal, complications for both the mother and baby. Complications of preeclampsia include fetal growth restriction, low birth weight, preterm birth, placental abruption, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count syndrome), eclampsia (a severe form of preeclampsia that leads to seizures), organ damage, including kidney, liver, lung, heart, or eye damage, stroke or other brain injury. See, for example, “Preeclampsia—Symptoms and causes—Mayo Clinic,” Apr. 3, 2018, available at on the worldwide web at mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/syc-20355745.

With early detection and treatment, most women can deliver a healthy baby if preeclampsia is detected early and treated with regular prenatal care. Although various protein biomarkers display changed levels in maternal serum at presymptomatic stages, these biomarkers lack discriminative and predictive power in individual patients (Karumanchi and Granger, 2016, Hypertension; 67(2): 238-242). Thus, the identification of biomarkers for the early detection of preeclampsia is critical for the early diagnosis and treatment of preeclampsia.

SUMMARY OF THE INVENTION

The present invention includes a method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method including:

identifying in a biosample obtained from the pregnant women a plurality of circulating RNA (C-RNA) molecules;

wherein a plurality of C-RNA molecules is selected from:

-   -   (a) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve, any thirteen or         more, any fourteen or more, any fifteen or more, any sixteen or         more, any seventeen or more, any eighteen or more, any nineteen         or more, any twenty or more, any twenty one or more, any twenty         two or more, any twenty three or more, any twenty four or more,         any twenty five or more, up to all seventy-five of ARRDC2, JUN,         SKIL, ATP13A3, PDE8B, GSTA3, PAPPA2, TIPARP, LEP, RGP1, USP54,         CLEC4C, MRPS35, ARHGEF25, CUX2, HEATR9, FSTL3, DDI2, ZMYM6,         ST6GALNAC3, GBP2, NES, ETV3, ADAM17, ATOH8, SLC4A3, TRAF3IP1,         TTC21A, HEG1, ASTE1, TMEM108, ENC1, SCAMP1, ARRDC3, SLC26A2,         SLIT3, CLIC5, TNFRSF21, PPP1R17, TPST1, GATSL2, SPDYE5, HIPK2,         MTRNR2L6, CLCN1, GINS4, CRH, C10orf2, TRUB1, PRG2, ACY3, FAR2,         CD63, CKAP4, TPCN1, RNF6, THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3,         SERPINF1, TMEM11, PSMD11, EBI3, CLEC4M, CCDC151, CPAMD8, CNFN,         LILRA4, ADA, C22orf39, PI4KAP1, and ARFGAP3; or     -   (b) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve or more, any         thirteen or more, any fourteen or more, any fifteen or more, any         sixteen or more, any seventeen or more, any eighteen or more,         any nineteen or more, any twenty or more, any twenty one or         more, any twenty two or more, any twenty three or more, any         twenty four or more, any twenty five or more, any twenty six of         more, or all twenty-seven of TIMP4, FLG, HTRA4, AMPH, LCN6, CRH,         TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3,         IGFBP5, HSPA12B, CLEC4C, KRT5, PRG2, PRX, ARHGEF25, ADAMTS2,         DAAM2, FAM107A, LEP, NES, and VSIG4; or     -   (c) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve, any thirteen or         more, any fourteen or more, any fifteen or more, any sixteen or         more, any seventeen or more, any eighteen or more, any nineteen         or more, any twenty or more, any twenty one or more, any twenty         two or more, any twenty three or more, any twenty four or more,         any twenty five or more, up to all one hundred twenty-two of         CYP26B1, IRF6, MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366,         ADCY1, C6, FAM219A, HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2,         SULT2A1, FMO3, FSTL3, GATA5, HTRA1, C8B, H19, MN1, NFE2L1,         PRDM16, AP3B2, EMP1, FLNC, STAG3, CPB2, TENC1, RP1L1, A1CF,         NPR1, TEK, ERRFI1, ARHGEF15, CD34, RSPO3, ALPK3, SAMD4A,         ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16, SERPINA3, AQP7, SRPX, UACA,         ANO1, FKBPS, SCN5A, PTPN21, CACNA1C, ERG, SOX17, WWTR1, AIF1L,         CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO, FN1, GPR116, KRT17, AZGP1,         BCL6B, KIF1C, CLIC5, GPR4, GJA5, OLAH, C14orf37, ZEB1, JAG2,         KIF26A, APOLD1, PNMT, MYOM3, PITPNM3, TIMP4, HTRA4, AMPH, LCN6,         CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2,         TIMP3, IGFBP5, HSPA12B, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2,         FAM107A, LEP, NES, VSIG4, HBG2, CADM2, LAMPS, PTGDR2, NOMO1,         NXF3, PLD4, BPIFB3, PACSIN1, CUX2, FLG, CLEC4C, and KRT5; or     -   (d) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve or more, any         thirteen or more, any fourteen or more, any fifteen or more, any         sixteen or more, any seventeen or more, any eighteen or more,         any nineteen or more, any twenty or more, any twenty-one or         more, any twenty-two or more, any twenty-three or more, any         twenty-four or more, any twenty-five or more, any twenty-six or         more, any twenty-seven or more, any twenty-eight or more, any         twenty-nine or more, or all thirty of VSIG4, ADAMTS2, NES,         FAM107A, LEP, DAAM2, ARHGEF25, TIMP3, PRX, ALOX15B, HSPA12B,         IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1, SEMA3G, KRT5, AMPH, PRG2,         PAPPA2, TEAD4, CRH, PITPNM3, TIMP4, PNMT, ZEB1, APOLD1, PLD4,         CUX2, and HTRA4; or     -   (e) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve or more, any         thirteen or more, any fourteen or more, any fifteen or more, any         sixteen or more, any seventeen or more, any eighteen or more,         any nineteen or more, any twenty or more, any twenty-one or         more, any twenty-two or more, any twenty-three or more, any         twenty-four or more, any twenty-five or more, or all twenty-six         of ADAMTS1, ADAMTS2, ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2,         FAM107A, HSPA12B, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26,         NES, OLAH, PACSIN1, PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2,         TIMP3, and VSIG4; or     -   (f) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve or more, any         thirteen or more, any fourteen or more, any fifteen or more, any         sixteen or more, any seventeen or more, any eighteen or more,         any nineteen or more, any twenty or more, any twenty-one or         more, or all twenty-two of ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25,         CELF4, DAAM2, FAM107A, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP,         LRRC26, NES, OLAH, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and         VSIG4; or     -   (g) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, or all eleven of CLEC4C, ARHGEF25, ADAMTS2,         LEP, ARRDC2, SKIL, PAPPA2, VSIG4, ARRDC4, CRH, and NES         (including in some embodiments, the seven of ADAMTS2, ARHGEF25,         ARRDC2, CLEC4C, LEP, PAPPA2, and VSIG4; the eight of ADAMTS2,         ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, SKIL, and VSIG4; the         eight of ADAMTS2, ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, and         VSIG4; the ten of ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C,         CRH, LEP, PAPPA2, SKIL, and VSIG4; the of six of ADAMTS2,         ARHGEF25, ARRDC2, CLEC4C, LEP, and SKIL; or the eight of         ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, and         SKIL); or     -   (h) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve or more, any         thirteen or more, any fourteen or more, any fifteen or more, any         sixteen or more, any seventeen or more, any eighteen or more,         any nineteen or more, any twenty or more, any twenty-one or         more, any twenty-two or more, any twenty-three or more, or all         twenty-four of LEP, PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3,         ARHGEF25, ADA, HTRA4, NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1,         SERPINF1, SKIL, SEMA3G, TIPARP, LRRC26, PHEX, LILRA4, and PER1;         or     -   (i) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve, any thirteen or         more, any fourteen or more, any fifteen or more, any sixteen or         more, any seventeen or more, any eighteen or more, any nineteen         or more, any twenty or more, any twenty one or more, any twenty         two or more, any twenty three or more, any twenty four or more,         any twenty five or more, any twenty-six or more, any         twenty-seven or more, any twenty-eight or more, any twenty-nine         or more, any thirty or more, any thirty-one or more, any         thirty-two or more, any thirty-three or more, any thirty-four or         more, any thirty-five or more, any thirty-six or more, any         thirty-seven or more, any thirty-eight or more, any thirty-nine         or more, any forty or more, any forty-one or more, any forty-two         or more, any forty-three or more, any forty-four or more, any         forty-five or more, any forty-six or more, any forty-seven or         more, any forty-eight or more, or all forth-nine of those listed         in Table S9 of Example 7; or     -   (j) a plurality of C-RNA molecules encoding at least a portion         of a protein selected from any one or more, any two or more, any         three or more, any four or more, any five or more, any six or         more, any seven or more, any eight or more, any nine or more,         any ten or more, any eleven or more, any twelve or more, or all         thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2,         PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768 is indicative of         preeclampsia and/or an increased risk for preeclampsia in the         pregnant women.

The present invention includes a method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method including:

obtaining a biosample from the pregnant female;

purifying a population of circulating RNA (C-RNA) molecules from the biosample;

identifying protein coding sequences encoded by the C-RNA molecules within the purified population of C-RNA molecules;

wherein protein coding sequences encoded by the C-RNA molecules encoding at least a portion of a protein is selected from:

-   -   (a) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, any fifty or more, any seventy or more, or all         seventy-five of ARRDC2, JUN, SKIL, ATP13A3, PDE8B, GSTA3,         PAPPA2, TIPARP, LEP, RGP1, USP54, CLEC4C, MRPS35, ARHGEF25,         CUX2, HEATR9, FSTL3, DDI2, ZMYM6, ST6GALNAC3, GBP2, NES, ETV3,         ADAM17, ATOH8, SLC4A3, TRAF3IP1, TTC21A, HEG1, ASTE1, TMEM108,         ENC1, SCAMP1, ARRDC3, SLC26A2, SLIT3, CLIC5, TNFRSF21, PPP1R17,         TPST1, GATSL2, SPDYE5, HIPK2, MTRNR2L6, CLCN1, GINS4, CRH,         C10orf2, TRUB1, PRG2, ACY3, FAR2, CD63, CKAP4, TPCN1, RNF6,         THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3, SERPINF1, TMEM11, PSMD11,         EBI3, CLEC4M, CCDC151, CPAMD8, CNFN, LILRA4, ADA, C22orf39,         PI4KAP1, and ARFGAP3; or     -   (b) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty one or more, any twenty two or         more, any twenty three or more, any twenty four or more, any         twenty five or more, any twenty six of more, or all twenty-seven         of TIMP4, FLG, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2,         SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, H5PA12B,         CLEC4C, KRT5, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP,         NES, and VSIG4; or     -   (c) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, any fifty or more, any seventy-five or more, any one         hundred or more, or all one hundred twenty-two of CYP26B1, IRF6,         MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366, ADCY1, C6, FAM219A,         HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2, SULT2A1, FMO3, FSTL3,         GATA5, HTRA1, C8B, H19, MN1, NFE2L1, PRDM16, AP3B2, EMP1, FLNC,         STAG3, CPB2, TENC1, RP1L1, A1CF, NPR1, TEK, ERRFI1, ARHGEF15,         CD34, RSPO3, ALPK3, SAMD4A, ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16,         SERPINA3, AQP7, SRPX, UACA, ANO1, FKBPS, SCN5A, PTPN21, CACNA1C,         ERG, SOX17, WWTR1, AIF1L, CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO,         FN1, GPR116, KRT17, AZGP1, BCL6B, KIF1C, CLIC5, GPR4, GJA5,         OLAH, C14orf37, ZEB1, JAG2, KIF26A, APOLD1, PNMT, MYOM3,         PITPNM3, TIMP4, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2,         SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B,         PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, VSIG4,         HBG2, CADM2, LAMPS, PTGDR2, NOMO1, NXF3, PLD4, BPIFB3, PACSIN1,         CUX2, FLG, CLEC4C, and KRT5; or     -   (d) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, any twenty-four or more, any         twenty-five or more, any twenty-six or more, any twenty-seven or         more, any twenty-eight or more, any twenty-nine or more, or all         thirty of VSIG4, ADAMTS2, NES, FAM107A, LEP, DAAM2, ARHGEF25,         TIMP3, PRX, ALOX15B, HSPA12B, IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1,         SEMA3G, KRT5, AMPH, PRG2, PAPPA2, TEAD4, CRH, PITPNM3, TIMP4,         PNMT, ZEB1, APOLD1, PLD4, CUX2, and HTRA4; or     -   (e) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, any twenty-four or more, any         twenty-five or more, or all twenty-six of ADAMTS1, ADAMTS2,         ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2, FAM107A, HSPA12B, HTRA4,         IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PACSIN1,         PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4; or     -   (f) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, or all twenty-two of         ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25, CELF4, DAAM2, FAM107A,         HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PRX,         PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4; or     -   (g) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, or         all eleven of CLEC4C, ARHGEF25, ADAMTS2, LEP, ARRDC2, SKIL,         PAPPA2, VSIG4, ARRDC4, CRH, and NES (including in some         embodiments, the seven of ADAMTS2, ARHGEF25, ARRDC2, CLEC4C,         LEP, PAPPA2, and VSIG4; the eight of ADAMTS2, ARHGEF25, ARRDC2,         CLEC4C, LEP, PAPPA2, SKIL, and VSIG4; the eight of ADAMTS2,         ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, and VSIG4; the ten of         ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, PAPPA2,         SKIL, and VSIG4; the of six of ADAMTS2, ARHGEF25, ARRDC2,         CLEC4C, LEP, and SKIL; or the eight of ADAMTS2, ARHGEF25,         ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, and SKIL); or     -   (h) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, or all twenty-four of LEP,         PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3, ARHGEF25, ADA, HTRA4,         NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1, SERPINF1, SKIL,         SEMA3G, TIPARP, LRRC26, PHEX, LILRA4, and PER1; or     -   (i) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, any twenty-six or more, any twenty-seven or more, any         twenty-eight or more, any twenty-nine or more, any thirty or         more, any thirty-one or more, any thirty-two or more, any         thirty-three or more, any thirty-four or more, any thirty-five         or more, any thirty-six or more, any thirty-seven or more, any         thirty-eight or more, any thirty-nine or more, any forty or         more, any forty-one or more, any forty-two or more, any         forty-three or more, any forty-four or more, any forty-five or         more, any forty-six or more, any forty-seven or more, any         forty-eight or more, or all forth-nine of those listed in Table         S9 of Example 7; or     -   (j) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, or all thirteen of AKAP2,         ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG,         TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or         an increased risk for preeclampsia in the pregnant women.

In some aspects, identifying protein coding sequences encoded by C-RNA molecules within the biosample includes hybridization, reverse transcriptase PCR, microarray chip analysis, or sequencing.

In some aspects, identifying protein coding sequences encoded by the C-RNA molecules within the biosample includes sequencing, including, for example, massively parallel sequencing of clonally amplified molecules and/or RNA sequencing.

In some aspects, the method further includes removing intact cells from the biosample; treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA); synthesizing complementary DNA (cDNA) from C-RNA molecules in the biosample; and/or enriching the cDNA sequences for DNA sequences that encode proteins by exome enrichment prior to identifying protein coding sequence encoded by the circulating RNA (C-RNA) molecules.

The present invention includes a method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method including:

obtaining a biological sample from the pregnant female;

removing intact cells from the biosample;

treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA);

synthesizing complementary DNA (cDNA) from RNA molecules in the biosample;

enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment);

sequencing the resulting enriched cDNA sequences; and

identifying protein coding sequences encoded by enriched C-RNA molecules;

wherein protein coding sequences encoded by the C-RNA molecules encoding at least a portion of a protein selected from:

-   -   (a) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, up to all seventy-five of ARRDC2, JUN, SKIL, ATP13A3,         PDE8B, GSTA3, PAPPA2, TIPARP, LEP, RGP1, USP54, CLEC4C, MRPS35,         ARHGEF25, CUX2, HEATR9, FSTL3, DDI2, ZMYM6, ST6GALNAC3, GBP2,         NES, ETV3, ADAM17, ATOH8, SLC4A3, TRAF3IP1, TTC21A, HEG1, ASTE1,         TMEM108, ENC1, SCAMP1, ARRDC3, SLC26A2, SLIT3, CLIC5, TNFRSF21,         PPP1R17, TPST1, GATSL2, SPDYE5, HIPK2, MTRNR2L6, CLCN1, GINS4,         CRH, C10orf2, TRUB1, PRG2, ACY3, FAR2, CD63, CKAP4, TPCN1, RNF6,         THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3, SERPINF1, TMEM11, PSMD11,         EBI3, CLEC4M, CCDC151, CPAMD8, CNFN, LILRA4, ADA, C22orf39,         PI4KAP1, and ARFGAP3; or     -   (b) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, any twenty six of more, or all twenty-seven of TIMP4,         FLG, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G,         ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, CLEC4C,         KRT5, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES,         and VSIG4; or     -   (c) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty one or more, any twenty two or         more, any twenty three or more, any twenty four or more, any         twenty five or more, up to all one hundred twenty-two of         CYP26B1, IRF6, MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366,         ADCY1, C6, FAM219A, HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2,         SULT2A1, FMO3, FSTL3, GATA5, HTRA1, C8B, H19, MN1, NFE2L1,         PRDM16, AP3B2, EMP1, FLNC, STAG3, CPB2, TENC1, RP1L1, A1CF,         NPR1, TEK, ERRFI1, ARHGEF15, CD34, RSPO3, ALPK3, SAMD4A,         ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16, SERPINA3, AQP7, SRPX, UACA,         ANO1, FKBPS, SCN5A, PTPN21, CACNA1C, ERG, SOX17, WWTR1, AIF1L,         CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO, FN1, GPR116, KRT17, AZGP1,         BCL6B, KIF1C, CLIC5, GPR4, GJA5, OLAH, C14orf37, ZEB1, JAG2,         KIF26A, APOLD1, PNMT, MYOM3, PITPNM3, TIMP4, HTRA4, AMPH, LCN6,         CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2,         TIMP3, IGFBP5, HSPA12B, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2,         FAM107A, LEP, NES, VSIG4, HBG2, CADM2, LAMPS, PTGDR2, NOMO1,         NXF3, PLD4, BPIFB3, PACSIN1, CUX2, FLG, CLEC4C, and KRT5; or     -   (d) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, any twenty-four or more, any         twenty-five or more, any twenty-six or more, any twenty-seven or         more, any twenty-eight or more, any twenty-nine or more, or all         thirty of VSIG4, ADAMTS2, NES, FAM107A, LEP, DAAM2, ARHGEF25,         TIMP3, PRX, ALOX15B, HSPA12B, IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1,         SEMA3G, KRT5, AMPH, PRG2, PAPPA2, TEAD4, CRH, PITPNM3, TIMP4,         PNMT, ZEB1, APOLD1, PLD4, CUX2, and HTRA4; or     -   (e) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, any twenty-four or more, any         twenty-five or more, or all twenty-six of ADAMTS1, ADAMTS2,         ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2, FAM107A, HSPA12B, HTRA4,         IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PACSIN1,         PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4; or     -   (f) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, or all twenty-two of         ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25, CELF4, DAAM2, FAM107A,         HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PRX,         PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4; or     -   (g) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, or         all eleven of CLEC4C, ARHGEF25, ADAMTS2, LEP, ARRDC2, SKIL,         PAPPA2, VSIG4, ARRDC4, CRH, and NES (including in some         embodiments, the seven of ADAMTS2, ARHGEF25, ARRDC2, CLEC4C,         LEP, PAPPA2, and VSIG4; the eight of ADAMTS2, ARHGEF25, ARRDC2,         CLEC4C, LEP, PAPPA2, SKIL, and VSIG4; the eight of ADAMTS2,         ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, and VSIG4; the ten of         ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, PAPPA2,         SKIL, and VSIG4; the of six of ADAMTS2, ARHGEF25, ARRDC2,         CLEC4C, LEP, and SKIL; or the eight of ADAMTS2, ARHGEF25,         ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, and SKIL); or     -   (h) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, or all twenty-four of LEP,         PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3, ARHGEF25, ADA, HTRA4,         NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1, SERPINF1, SKIL,         SEMA3G, TIPARP, LRRC26, PHEX, LILRA4, and PER1; or     -   (i) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, any twenty-six or more, any twenty-seven or more, any         twenty-eight or more, any twenty-nine or more, any thirty or         more, any thirty-one or more, any thirty-two or more, any         thirty-three or more, any thirty-four or more, any thirty-five         or more, any thirty-six or more, any thirty-seven or more, any         thirty-eight or more, any thirty-nine or more, any forty or         more, any forty-one or more, any forty-two or more, any         forty-three or more, any forty-four or more, any forty-five or         more, any forty-six or more, any forty-seven or more, any         forty-eight or more, or all forth-nine of those listed in Table         S9 of Example 7; or     -   (j) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, or all thirteen of AKAP2,         ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG,         TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or         an increased risk for preeclampsia in the pregnant women.

The present invention includes a method of identifying a circulating RNA signature associated with an increased risk of preeclampsia, the method including obtaining a biological sample from the pregnant female; removing intact cells from the biosample; treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA); synthesizing complementary DNA (cDNA) from RNA molecules in the biosample; enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment); sequencing the resulting enriched cDNA sequences; and identifying protein coding sequences encoded by enriched C-RNA molecules.

The present invention includes a method including:

obtaining a biological sample from the pregnant female;

removing intact cells from the biosample;

treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA);

synthesizing complementary DNA (cDNA) from RNA molecules in the biosample;

enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment);

sequencing the resulting enriched cDNA sequences; and

identifying protein coding sequences encoded by the enriched C-RNA molecules;

wherein the protein coding sequences include at least a portion of a protein selected from:

-   -   (a) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         up to all seventy-five ARRDC2, JUN, SKIL, ATP13A3, PDE8B, GSTA3,         PAPPA2, TIPARP, LEP, RGP1, USP54, CLEC4C, MRPS35, ARHGEF25,         CUX2, HEATR9, FSTL3, DDI2, ZMYM6, ST6GALNAC3, GBP2, NES, ETV3,         ADAM17, ATOH8, SLC4A3, TRAF3IP1, TTC21A, HEG1, ASTE1, TMEM108,         ENC1, SCAMP1, ARRDC3, SLC26A2, SLIT3, CLIC5, TNFRSF21, PPP1R17,         TPST1, GATSL2, SPDYE5, HIPK2, MTRNR2L6, CLCN1, GINS4, CRH,         C10orf2, TRUB1, PRG2, ACY3, FAR2, CD63, CKAP4, TPCN1, RNF6,         THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3, SERPINF1, TMEM11, PSMD11,         EBI3, CLEC4M, CCDC151, CPAMD8, CNFN, LILRA4, ADA, C22orf39,         PI4KAP1, and ARFGAP3; or     -   (b) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty one or more, any twenty two or         more, any twenty three or more, any twenty four or more, any         twenty five or more, any twenty six of more, or all twenty-seven         of TIMP4, FLG, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2,         SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B,         CLEC4C, KRT5, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP,         NES, and VSIG4; or     -   (c) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, up to all one hundred twenty-two of CYP26B1, IRF6,         MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366, ADCY1, C6, FAM219A,         HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2, SULT2A1, FMO3, FSTL3,         GATA5, HTRA1, C8B, H19, MN1, NFE2L1, PRDM16, AP3B2, EMP1, FLNC,         STAG3, CPB2, TENC1, RP1L1, A1CF, NPR1, TEK, ERRFI1, ARHGEF15,         CD34, RSPO3, ALPK3, SAMD4A, ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16,         SERPINA3, AQP7, SRPX, UACA, ANO1, FKBPS, SCN5A, PTPN21, CACNA1C,         ERG, SOX17, WWTR1, AIF1L, CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO,         FN1, GPR116, KRT17, AZGP1, BCL6B, KIF1C, CLIC5, GPR4, GJA5,         OLAH, C14orf37, ZEB1, JAG2, KIF26A, APOLD1, PNMT, MYOM3,         PITPNM3, TIMP4, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2,         SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B,         PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, VSIG4,         HBG2, CADM2, LAMPS, PTGDR2, NOMO1, NXF3, PLD4, BPIFB3, PACSIN1,         CUX2, FLG, CLEC4C, and KRT5; or     -   (d) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, any twenty-four or more, any         twenty-five or more, any twenty-six or more, any twenty-seven or         more, any twenty-eight or more, any twenty-nine or more, or all         thirty of VSIG4, ADAMTS2, NES, FAM107A, LEP, DAAM2, ARHGEF25,         TIMP3, PRX, ALOX15B, HSPA12B, IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1,         SEMA3G, KRT5, AMPH, PRG2, PAPPA2, TEAD4, CRH, PITPNM3, TIMP4,         PNMT, ZEB1, APOLD1, PLD4, CUX2, and HTRA4; or     -   (e) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, any twenty-four or more, any         twenty-five or more, or all twenty-six of ADAMTS1, ADAMTS2,         ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2, FAM107A, HSPA12B, HTRA4,         IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PACSIN1,         PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4; or     -   (f) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, or all twenty-two of         ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25, CELF4, DAAM2, FAM107A,         HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PRX,         PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4; or     -   (g) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, or         all eleven of CLEC4C, ARHGEF25, ADAMTS2, LEP, ARRDC2, SKIL,         PAPPA2, VSIG4, ARRDC4, CRH, and NES (including in some         embodiments, the seven of ADAMTS2, ARHGEF25, ARRDC2, CLEC4C,         LEP, PAPPA2, and VSIG4; the eight of ADAMTS2, ARHGEF25, ARRDC2,         CLEC4C, LEP, PAPPA2, SKIL, and VSIG4; the eight of ADAMTS2,         ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, and VSIG4; the ten of         ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, PAPPA2,         SKIL, and VSIG4; the of six of ADAMTS2, ARHGEF25, ARRDC2,         CLEC4C, LEP, and SKIL; or the eight of ADAMTS2, ARHGEF25,         ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, and SKIL); or     -   (h) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, any thirteen or more, any         fourteen or more, any fifteen or more, any sixteen or more, any         seventeen or more, any eighteen or more, any nineteen or more,         any twenty or more, any twenty-one or more, any twenty-two or         more, any twenty-three or more, or all twenty-four of LEP,         PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3, ARHGEF25, ADA, HTRA4,         NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1, SERPINF1, SKIL,         SEMA3G, TIPARP, LRRC26, PHEX, LILRA4, and PER1; or     -   (i) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve, any thirteen or more, any fourteen         or more, any fifteen or more, any sixteen or more, any seventeen         or more, any eighteen or more, any nineteen or more, any twenty         or more, any twenty one or more, any twenty two or more, any         twenty three or more, any twenty four or more, any twenty five         or more, any twenty-six or more, any twenty-seven or more, any         twenty-eight or more, any twenty-nine or more, any thirty or         more, any thirty-one or more, any thirty-two or more, any         thirty-three or more, any thirty-four or more, any thirty-five         or more, any thirty-six or more, any thirty-seven or more, any         thirty-eight or more, any thirty-nine or more, any forty or         more, any forty-one or more, any forty-two or more, any         forty-three or more, any forty-four or more, any forty-five or         more, any forty-six or more, any forty-seven or more, any         forty-eight or more, or all forth-nine of those listed in Table         S9 of Example 7; or     -   (j) any one or more, any two or more, any three or more, any         four or more, any five or more, any six or more, any seven or         more, any eight or more, any nine or more, any ten or more, any         eleven or more, any twelve or more, or all thirteen of AKAP2,         ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG,         TRPS1, UBE2Q1, and ZNF768.

In some aspects, the biosample includes plasma.

In some aspects, the biosample is obtained from a pregnant female at less than 16 weeks gestation or at less than 20 weeks gestation.

In some aspects, the biosample is obtained from a pregnant female at greater than 20 weeks gestation.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any fifty or more, any seventy or more, up to all seventy-five ARRDC2, JUN, SKIL, ATP13A3, PDE8B, GSTA3, PAPPA2, TIPARP, LEP, RGP1, USP54, CLEC4C, MRPS35, ARHGEF25, CUX2, HEATR9, FSTL3, DDI2, ZMYM6, ST6GALNAC3, GBP2, NES, ETV3, ADAM17, ATOH8, SLC4A3, TRAF3IP1, TTC21A, HEG1, ASTE1, TMEM108, ENC1, SCAMP1, ARRDC3, SLC26A2, SLIT3, CLIC5, TNFRSF21, PPP1R17, TPST1, GATSL2, SPDYE5, HIPK2, MTRNR2L6, CLCN1, GINS4, CRH, C10orf2, TRUB1, PRG2, ACY3, FAR2, CD63, CKAP4, TPCN1, RNF6, THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3, SERPINF1, TMEM11, PSMD11, EBI3, CLEC4M, CCDC151, CPAMD8, CNFN, LILRA4, ADA, C22orf39, PI4KAP1, and ARFGAP3.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty six of more, or all twenty-seven of TIMP4, FLG, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, CLEC4C, KRT5, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, and VSIG4.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding a least a portion of a plurality of CYP26B1, IRF6, MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366, ADCY1, C6, FAM219A, HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2, SULT2A1, FMO3, FSTL3, GATA5, HTRA1, C8B, H19, MN1, NFE2L1, PRDM16, AP3B2, EMP1, FLNC, STAG3, CPB2, TENC1, RP1L1, A1CF, NPR1, TEK, ERRF1, ARHGEF15, CD34, RSPO3, ALPK3, SAMD4A, ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16, SERPINA3, AQP7, SRPX, UACA, ANO1, FKBPS, SCN5A, PTPN21, CACNA1C, ERG, SOX17, WWTR1, AIF1L, CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO, FN1, GPR116, KRT17, AZGP1, BCL6B, KIF1C, CLIC5, GPR4, GJA5, OLAH, C14orf37, ZEB1, JAG2, KIF26A, APOLD1, PNMT, MYOM3, PITPNM3, TIMP4, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, VSIG4, HBG2, CADM2, LAMPS, PTGDR2, NOMO1, NXF3, PLD4, BPIFB3, PACSIN1, CUX2, FLG, CLEC4C, and KRT5.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty-one or more, any twenty-two or more, any twenty-three or more, any twenty-four or more, any twenty-five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, or all thirty of VSIG4, ADAMTS2, NES, FAM107A, LEP, DAAM2, ARHGEF25, TIMP3, PRX, ALOX15B, HSPA12B, IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1, SEMA3G, KRT5, AMPH, PRG2, PAPPA2, TEAD4, CRH, PITPNM3, TIMP4, PNMT, ZEB1, APOLD1, PLD4, CUX2, and HTRA4.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty-one or more, any twenty-two or more, any twenty-three or more, any twenty-four or more, any twenty-five or more, or all twenty-six of ADAMTS1, ADAMTS2, ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2, FAM107A, HSPA12B, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PACSIN1, PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty-one or more, or all twenty-two of ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25, CELF4, DAAM2, FAM107A, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, or all eleven of CLEC4C, ARHGEF25, ADAMTS2, LEP, ARRDC2, SKIL, PAPPA2, VSIG4, ARRDC4, CRH, and NES, including in some embodiments, the seven of ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, and VSIG4; the eight of ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, SKIL, and VSIG4; the eight of ADAMTS2, ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, and VSIG4; the ten of ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, PAPPA2, SKIL, and VSIG4; the of six of ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, and SKIL; or the eight of ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, and SKIL.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty-one or more, any twenty-two or more, any twenty-three or more, or all twenty-four of LEP, PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3, ARHGEF25, ADA, HTRA4, NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1, SERPINF1, SKIL, SEMA3G, TIPARP, LRRC26, PHEX, LILRA4, and PER1.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7.

The present invention includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature encoding at least a portion of any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768.

The present invention includes a solid support array comprising a plurality of agents capable of binding and/or identifying a C-RNA signature as described herein.

The present invention includes a kit comprising a plurality of probes capable of binding and/or identifying a C-RNA signature as described herein.

The present invention includes a kit comprising a plurality of primers for selectively amplifying a C-RNA signature as described herein.

As used herein, the term “nucleic acid” is intended to be consistent with its use in the art and includes naturally occurring nucleic acids or functional analogs thereof. Particularly useful functional analogs are capable of hybridizing to a nucleic acid in a sequence specific fashion or capable of being used as a template for replication of a particular nucleotide sequence. Naturally occurring nucleic acids generally have a backbone containing phosphodiester bonds. An analog structure can have an alternate backbone linkage including any of a variety of those known in the art. Naturally occurring nucleic acids generally have a deoxyribose sugar (e.g. found in deoxyribonucleic acid (DNA)) or a ribose sugar (e.g. found in ribonucleic acid (RNA)). A nucleic acid can contain any of a variety of analogs of these sugar moieties that are known in the art. A nucleic acid can include native or non-native bases. In this regard, a native deoxyribonucleic acid can have one or more bases selected from the group consisting of adenine, thymine, cytosine or guanine and a ribonucleic acid can have one or more bases selected from the group consisting of uracil, adenine, cytosine or guanine. Useful non-native bases that can be included in a nucleic acid are known in the art. The term “template” and “target,” when used in reference to a nucleic acid, is intended as a semantic identifier for the nucleic acid in the context of a method or composition set forth herein and does not necessarily limit the structure or function of the nucleic acid beyond what is otherwise explicitly indicated.

As used herein, “amplify,” “amplifying” or “amplification reaction” and their derivatives, refer generally to any action or process whereby at least a portion of a nucleic acid molecule is replicated or copied into at least one additional nucleic acid molecule. The additional nucleic acid molecule optionally includes sequence that is substantially identical or substantially complementary to at least some portion of the target nucleic acid molecule. The target nucleic acid molecule can be single-stranded or double-stranded and the additional nucleic acid molecule can independently be single-stranded or double-stranded. Amplification optionally includes linear or exponential replication of a nucleic acid molecule. In some embodiments, such amplification can be performed using isothermal conditions; in other embodiments, such amplification can include thermocycling. In some embodiments, the amplification is a multiplex amplification that includes the simultaneous amplification of a plurality of target sequences in a single amplification reaction. In some embodiments, “amplification” includes amplification of at least some portion of DNA and RNA based nucleic acids alone, or in combination. The amplification reaction can include any of the amplification processes known to one of ordinary skill in the art. In some embodiments, the amplification reaction includes polymerase chain reaction (PCR).

As used herein, “amplification conditions” and its derivatives, generally refers to conditions suitable for amplifying one or more nucleic acid sequences. Such amplification can be linear or exponential. In some embodiments, the amplification conditions can include isothermal conditions or alternatively can include thermocyling conditions, or a combination of isothermal and thermocycling conditions. In some embodiments, the conditions suitable for amplifying one or more nucleic acid sequences include polymerase chain reaction (PCR) conditions. Typically, the amplification conditions refer to a reaction mixture that is sufficient to amplify nucleic acids such as one or more target sequences, or to amplify an amplified target sequence ligated to one or more adapters, e.g., an adapter-ligated amplified target sequence. Generally, the amplification conditions include a catalyst for amplification or for nucleic acid synthesis, for example a polymerase; a primer that possesses some degree of complementarity to the nucleic acid to be amplified; and nucleotides, such as deoxyribonucleotide triphosphates (dNTPs) to promote extension of the primer once hybridized to the nucleic acid. The amplification conditions can require hybridization or annealing of a primer to a nucleic acid, extension of the primer and a denaturing step in which the extended primer is separated from the nucleic acid sequence undergoing amplification. Typically, but not necessarily, amplification conditions can include thermocycling; in some embodiments, amplification conditions include a plurality of cycles where the steps of annealing, extending and separating are repeated. Typically, the amplification conditions include cations such as Mg′ or Mn′ and can also include various modifiers of ionic strength.

As used herein, the term “polymerase chain reaction” (PCR) refers to the method of K. B. Mullis U.S. Pat. Nos. 4,683,195 and 4,683,202, which describes a method for increasing the concentration of a segment of a polynucleotide of interest in a mixture of genomic DNA without cloning or purification. This process for amplifying the polynucleotide of interest consists of introducing a large excess of two oligonucleotide primers to the DNA mixture containing the desired polynucleotide of interest, followed by a series of thermal cycling in the presence of a DNA polymerase. The two primers are complementary to their respective strands of the double-stranded polynucleotide of interest. The mixture is denatured at a higher temperature first and the primers are then annealed to complementary sequences within the polynucleotide of interest molecule. Following annealing, the primers are extended with a polymerase to form a new pair of complementary strands. The steps of denaturation, primer annealing and polymerase extension can be repeated many times (referred to as thermocycling) to obtain a high concentration of an amplified segment of the desired polynucleotide of interest. The length of the amplified segment of the desired polynucleotide of interest (amplicon) is determined by the relative positions of the primers with respect to each other, and therefore, this length is a controllable parameter. By virtue of repeating the process, the method is referred to as the “polymerase chain reaction” (hereinafter “PCR”). Because the desired amplified segments of the polynucleotide of interest become the predominant nucleic acid sequences (in terms of concentration) in the mixture, they are said to be “PCR amplified.” In a modification to the method discussed above, the target nucleic acid molecules can be PCR amplified using a plurality of different primer pairs, in some cases, one or more primer pairs per target nucleic acid molecule of interest, thereby forming a multiplex PCR reaction.

As used herein, the term “primer” and its derivatives refer generally to any polynucleotide that can hybridize to a target sequence of interest. Typically, the primer functions as a substrate onto which nucleotides can be polymerized by a polymerase; in some embodiments, however, the primer can become incorporated into the synthesized nucleic acid strand and provide a site to which another primer can hybridize to prime synthesis of a new strand that is complementary to the synthesized nucleic acid molecule. The primer can include any combination of nucleotides or analogs thereof. In some embodiments, the primer is a single-stranded oligonucleotide or polynucleotide. The terms “polynucleotide” and “oligonucleotide” are used interchangeably herein to refer to a polymeric form of nucleotides of any length, and may comprise ribonucleotides, deoxyribonucleotides, analogs thereof, or mixtures thereof. The terms should be understood to include, as equivalents, analogs of either DNA or RNA made from nucleotide analogs and to be applicable to single stranded (such as sense or antisense) and double-stranded polynucleotides. The term as used herein also encompasses cDNA, that is complementary or copy DNA produced from an RNA template, for example by the action of reverse transcriptase. This term refers only to the primary structure of the molecule. Thus, the term includes triple-, double- and single-stranded deoxyribonucleic acid (“DNA”), as well as triple-, double- and single-stranded ribonucleic acid (“RNA”).

As used herein, the terms “library” and “sequencing library” refer to a collection or plurality of template molecules which share common sequences at their 5′ ends and common sequences at their 3′ ends. The collection of template molecules containing known common sequences at their 3′ and 5′ ends may also be referred to as a 3′ and 5′ modified library.

The term “flowcell” as used herein refers to a chamber comprising a solid surface across which one or more fluid reagents can be flowed. Examples of flowcells and related fluidic systems and detection platforms that can be readily used in the methods of the present disclosure are described, for example, in Bentley et al., Nature 456:53-59 (2008), WO 04/018497; U.S. Pat. No. 7,057,026; WO 91/06678; WO 07/123744; U.S. Pat. Nos. 7,329,492; 7,211,414; 7,315,019; 7,405,281, and US 2008/0108082.

As used herein, the term “amplicon,” when used in reference to a nucleic acid, means the product of copying the nucleic acid, wherein the product has a nucleotide sequence that is the same as or complementary to at least a portion of the nucleotide sequence of the nucleic acid. An amplicon can be produced by any of a variety of amplification methods that use the nucleic acid, or an amplicon thereof, as a template including, for example, PCR, rolling circle amplification (RCA), ligation extension, or ligation chain reaction. An amplicon can be a nucleic acid molecule having a single copy of a particular nucleotide sequence (e.g. a PCR product) or multiple copies of the nucleotide sequence (e.g. a concatameric product of RCA). A first amplicon of a target nucleic acid is typically a complimentary copy. Subsequent amplicons are copies that are created, after generation of the first amplicon, from the target nucleic acid or from the first amplicon. A subsequent amplicon can have a sequence that is substantially complementary to the target nucleic acid or substantially identical to the target nucleic acid.

As used herein, the term “array” refers to a population of sites that can be differentiated from each other according to relative location. Different molecules that are at different sites of an array can be differentiated from each other according to the locations of the sites in the array. An individual site of an array can include one or more molecules of a particular type. For example, a site can include a single target nucleic acid molecule having a particular sequence or a site can include several nucleic acid molecules having the same sequence (and/or complementary sequence, thereof). The sites of an array can be different features located on the same substrate. Exemplary features include without limitation, wells in a substrate, beads (or other particles) in or on a substrate, projections from a substrate, ridges on a substrate or channels in a substrate. The sites of an array can be separate substrates each bearing a different molecule. Different molecules attached to separate substrates can be identified according to the locations of the substrates on a surface to which the substrates are associated or according to the locations of the substrates in a liquid or gel. Exemplary arrays in which separate substrates are located on a surface include, without limitation, those having beads in wells.

The term “Next Generation Sequencing (NGS)” herein refers to sequencing methods that allow for massively parallel sequencing of clonally amplified molecules and of single nucleic acid molecules. Non-limiting examples of NGS include sequencing-by-synthesis using reversible dye terminators, and sequencing-by-ligation.

The term “sensitivity” as used herein is equal to the number of true positives divided by the sum of true positives and false negatives.

The term “specificity” as used herein is equal to the number of true negatives divided by the sum of true negatives and false positives.

The term “enrich” herein refers to the process of amplifying nucleic acids contained in a portion of a sample. Enrichment includes specific enrichment that targets specific sequences, e.g., polymorphic sequences, and non-specific enrichment that amplifies the whole genome of the DNA fragments of the sample.

As used herein, the term “each,” when used in reference to a collection of items, is intended to identify an individual item in the collection but does not necessarily refer to every item in the collection unless the context clearly dictates otherwise.

As used herein, “providing” in the context of a composition, an article, a nucleic acid, or a nucleus means making the composition, article, nucleic acid, or nucleus, purchasing the composition, article, nucleic acid, or nucleus, or otherwise obtaining the compound, composition, article, or nucleus.

The term “and/or” means one or all of the listed elements or a combination of any two or more of the listed elements.

The words “preferred” and “preferably” refer to embodiments of the disclosure that may afford certain benefits, under certain circumstances. However, other embodiments may also be preferred, under the same or other circumstances. Furthermore, the recitation of one or more preferred embodiments does not imply that other embodiments are not useful, and is not intended to exclude other embodiments from the scope of the disclosure.

The terms “comprises” and variations thereof do not have a limiting meaning where these terms appear in the description and claims.

It is understood that wherever embodiments are described herein with the language “include,” “includes,” or “including,” and the like, otherwise analogous embodiments described in terms of “consisting of” and/or “consisting essentially of” are also provided.

Unless otherwise specified, “a,” “an,” “the,” and “at least one” are used interchangeably and mean one or more than one.

Also herein, the recitations of numerical ranges by endpoints include all numbers subsumed within that range (e.g., 1 to 5 includes 1, 1.5, 2, 2.75, 3, 3.80, 4, 5, etc.).

Reference throughout this specification to “one embodiment,” “an embodiment,” “certain embodiments,” or “some embodiments,” etc., means that a particular feature, configuration, composition, or characteristic described in connection with the embodiment is included in at least one embodiment of the disclosure. Thus, the appearances of such phrases in various places throughout this specification are not necessarily referring to the same embodiment of the disclosure. Furthermore, the particular features, configurations, compositions, or characteristics may be combined in any suitable manner in one or more embodiments.

For any method disclosed herein that includes discrete steps, the steps may be conducted in any feasible order. And, as appropriate, any combination of two or more steps may be conducted simultaneously.

The above summary of the present disclosure is not intended to describe each disclosed embodiment or every implementation of the present disclosure. The description that follows more particularly exemplifies illustrative embodiments. In several places throughout the application, guidance is provided through lists of examples, which examples can be used in various combinations. In each instance, the recited list serves only as a representative group and should not be interpreted as an exclusive list.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1. A schematic of the relationships between placental health, maternal response, and fetal response.

FIG. 2. Origins of circulating RNA (C-RNA).

FIG. 3. Library prep workflow for C-RNA.

FIG. 4. Validation of C-RNA approach comparing 3rd trimester pregnant and non-pregnant samples.

FIG. 5. Validation of C-RNA approach using longitudinal pregnancy samples.

FIG. 6. Description of clinical studies.

FIG. 7. Sequencing data characteristics.

FIG. 8. Classification of PE without any selection of genes, relying of entire data set.

FIG. 9. Description of bootstrapping method.

FIG. 10. Classification of preeclampsia samples with bootstrapping approach.

FIG. 11. Examination of over-abundant preeclampsia genes.

FIG. 12. Standard Adaboost Model.

FIG. 13. Independent cohort allows further validation of preeclampsia signature.

FIG. 14. Performance of standard adaboost model in classification of preeclampsia.

FIG. 15. Classification of preeclampsia with standard DEX TREAT analysis.

FIG. 16. Selection of genes and classification of preeclampsia with jackknifing approach.

FIG. 17. Validation of TREAT, Bootstrapping, and Jackknifing approaches in independent PEARL biobank cohort.

FIG. 18. A diagram of the bioinformatic approach to build AdaBoost Refined models.

FIG. 19. Relative abundance of genes utilized by AdaBoost Refined model and their predictive capability on independent datasets.

FIG. 20. Identifying C-RNA signatures specific to preeclampsia in Nextera Flex generated libraries using standard TREAT analysis and jackknifing approach.

FIG. 21. Relative abundance of genes utilized by AdaBoost Refined model on Nextera Flex generated libraries and their predictive power in RGH14 dataset.

FIGS. 22A-22D. Validation of a clinic-friendly, whole-exome C-RNA analysis method. FIG. 22A is a schematic of the sequencing library preparation method; all steps after blood collection can be performed in a centralized processing lab. Temporal changes of transcripts altered throughout the course of pregnancy (FIG. 22B). Overlap of genes identified in C-RNA pregnancy progression studies (FIG. 22C). Tissues expressing the 91 genes unique to the pregnancy time course study (FIG. 22D).

FIGS. 23A-23C. Sample collection for PE clinical studies. Panels illustrate the time of blood collection (triangles) and gestational age at birth (squares) for each individual in the iPC study (FIG. 23A) and the PEARL study (FIG. 23B). The red line indicates the threshold for term birth. Preterm birth rates are significantly elevated in early-onset PE cohorts (FIG. 23C). *** p<0.001 by Fisher's exact test.

FIGS. 24A-24G. Differential analysis of C-RNA identifies preeclampsia biomarkers. Fold change and abundance of transcripts altered in PE (FIG. 24A). One-sided confidence p-value intervals were calculated after jackknifing for each gene detected by standard analysis methods (FIG. 24B). Transcript abundance fold-change determined by whole exome sequencing and by qPCR for (21) genes (FIG. 24C). * p<0.05 by Student's T-test. Tissue distribution of affected genes (FIG. 24D). Hierarchical clustering of iPC samples (average linkage, squared Euclidean distance) (FIG. 24E). Clustering of early-onset PE (FIG. 24F) and late-onset PE (FIG. 24G) samples from the PEARL study.

FIGS. 25A-25E. AdaBoost classifies preeclampsia samples across cohorts. Heatmap illustrating the relative abundance of the transcripts used by machine learning in each cohort (FIG. 25A). The height of each block reflects each gene's importance. ROC curves for each dataset (FIG. 25B). Distributions (KDE) of AdaBoost Scores. The orange line indicates the optimal boundary to discriminate PE and control samples (FIG. 25C). Concordance of genes identified by differential analysis and those used in AdaBoost (FIG. 25D). Tissue distribution of AdaBoost genes (FIG. 25E).

FIGS. 26A-26C. C-RNA data integrity when blood is stored in different collection tubes. Comparing the abundance of previously detected C-RNA pregnancy markers from blood stored overnight in different tube types to immediate processing after collection in EDTA tubes (FIG. 26A). Scatterplots comparing transcript FPKM values for C-RNA prepared from the same individual after different blood storage durations (FIG. 26B). Pearson's correlation coefficient, R, is more variable when using EDTA tubes (cf, Cell-Free) (FIG. 26C).

FIGS. 27A and 27B. The effect of plasma volume on C-RNA data quality. A meta-analysis was performed with data from nine independent studies to determine the appropriate plasma input for the protocol. Noise (biological coefficient of variation, EdgeR) was calculated from biological replicates within each study (FIG. 27A). Library complexity (bound population, Preseq) was calculated for each sample (FIG. 27B). ** p<0.01, *** p<0.001 by ANOVA with Tukey's HSD correction, with study as a blocking variable.

FIGS. 28A-28C. Pregnancy marker tissue specificity. Pie charts showing tissue specificity of the genes detected in pregnancy by three independent studies, using either the full set of altered genes (FIG. 28A), the transcripts unique to each study (FIG. 28B), or intersecting gene sets (FIG. 28C).

FIGS. 29A-29E. Jackknifing excludes genes that are not universally altered in preeclampsia. Schematic of the jackknifing approach used to determine how consistently transcripts were altered across PE samples (FIG. 29A). Average abundance and noise for each differentially abundant gene (FIG. 29B). ROC area under the curve values for each affected transcript provide a measure of how separated C-RNA transcript abundance distributions are for control and PE samples (FIG. 29C). * p<0.05 by Mann-Whitney U test. Hierarchical clustering of iPC samples using the genes excluded after jackknifing (FIG. 29D). Tissue distribution of excluded transcripts (FIG. 29E). The decreased contribution of the fetus and placenta may suggest the maternal component of PE is most variable between individuals.

FIGS. 30A-30D. AdaBoost model development strategy. The RGH014 dataset was divided into 6 pieces (FIG. 30A). The “Holdout Subset” contained 10% of the samples (randomly selected) as well as the 3 samples which were incorrectly clustered when using differentially abundant genes (as with FIG. 24C) and was fully excluded from model building. The remaining samples were divided at random into 5 evenly sized “Test Subsets.” For each test subset, training data was composed of all non-holdout and non-testing samples. Gene counts for training and testing data were TMM-normalized in edgeR, and then standardized to mean 0 and standard deviation 1 for each gene. For each train/test sample set, AdaBoost models (90 estimators, 1.6 learning rate) were built 10 times from the training data (FIG. 30B). Feature pruning was performed, removing genes below an incrementally increasing importance threshold and assessing performance by Matthew's correlation coefficient when predicting testing data. The model with the best performance—and fewest genes, in the case of a tie—was retained. Estimators from all 50 independent models were combined into a single AdaBoost model (FIG. 30C). Feature pruning was performed on the resulting ensemble, this time using the percent of models which used a gene to set threshold values and performance measured by average log loss value across test subsets. ROC curve after applying the final AdaBoost model to the holdout data (FIG. 30D). All samples segregated correctly, except for two of the three samples which also misclustered by HCA.

FIGS. 31A-31E. The effect of hyperparameter selection and feature pruning on machine learning performance. Heatmap of a grid search to identify the optimal hyperparameters for AdaBoost (FIG. 31A). Matthew's correlation coefficient was used as a measure of performance. Flattened views of performance for each hyperparameter (FIG. 31B). Arrows indicate the values selected for model construction. FIG. 31C shows the impact of pruning individual AdaBoost models on performance (as in FIG. 30B). Solid lines are the average for all 10 models, and the shaded region shows the standard deviation. The number of AdaBoost models using each gene observed in the pre-pruned ensemble (FIG. 31D). Model performance when pruning the combined AdaBoost ensemble (FIG. 31E). The orange lines in FIG. 31D and FIG. 31E show the threshold applied to generate the final AdaBoost model.

FIGS. 32A-32C. Changes in the C-RNA transcriptome track with pregnancy progression. FIG. 32A shows temporal changes in transcripts significantly altered throughout the course of pregnancy. Each row corresponds to a transcript, the abundance of which was normalized across all samples (N=152) prior to clustering. Orange signifies elevated abundance; purple indicates decreased abundance. FIG. 32B shows the overlap of transcripts identified in three independent C-RNA pregnancy progression analyses. N=number of plasma samples collected from a pregnant woman in cohort. FIG. 32C shows tissues expressing the 91 genes that were only detected with the PEARL HCC cohort.

FIGS. 33A-33C. Sample collection but not clinical outcome is matched for control and PE samples. Panels illustrate the time of blood collection (triangles) and gestational age at birth (squares) for each individual in the iPEC study (FIG. 33A) and the PEARL PEC study (FIG. 33B). The red line indicates the threshold for term birth at 37 weeks. As shown in FIG. 33C, preterm birth rates are significantly elevated in early-onset PE cohorts. *** p<0.001 by Fisher's exact test. iPEC, Control N=73, PE N=40; PEARL PEC, N=12 for each group.

FIGS. 34A-34F. Applying jackknifing to differential expression analysis excludes genes with lower sensitivity for identifying PE samples. FIG. 34A shows fold change and abundance of transcripts altered in PE. FIG. 34B shows one-sided, normal-based 95% confidence intervals of the p-value for each transcript that was detected as altered by standard analyses. FIG. 34C is a schematic of the jackknifing approach, wherein 90% of samples were randomly selected for analysis over many iterations to quantify p-value stability. FIG. 34D shows average abundance and noise for each differentially abundant gene (p>0.05 for both variables by Mann-Whitney U; N=30,12). FIG. 34E shows ROC area under the curve values for each affected transcript reflect how separated C-RNA transcript abundance distributions are for control versus PE samples (* p<0.05 by Mann-Whitney U; Included, N=30; Excluded, N=12). FIG. 34F shows hierarchical clustering of iPEC samples using the genes excluded after jackknifing (sensitivity=73%; specificity=99%; N=113). For FIGS. 34A, 34B, 34D, and 34E orange and blue datapoints reflect transcripts considered statistically altered in PE by standard differential expression analysis, but only orange datapoint were identified by the jackknifing approach. Sample status is shown by the blue (PE) and gray (control) rectangles along the right side of the heatmap.

FIGS. 35A-35E. Ubiquitously altered C-RNA transcripts segregate early-onset PE samples from controls. FIG. 35A shows the fold-change between PE and control pregnancies was assessed both by sequencing (orange) and by qPCR (purple) for 20 transcripts (* p<0.05 by Student's T-test; N=19 for control and for PE). FIG. 35B shows tissue expression of affected genes. FIG. 35C shows hierarchical clustering of the iPEC samples (average linkage, squared Euclidean distance; PE, N=40; control, N=73). Clustering of early-onset (FIG. 35D) and late-onset (FIG. 35E) PE and control pregnancy samples from the PEARL PEC (N=12 for each group).

FIGS. 36A-36E. Machine learning accurately classifies PE across independent cohorts. FIG. 36A shows average ROC curve for iPEC validation samples (dashed line=SD; N=10). FIG. 36B shows accuracy, sensitivity and specificity measurements if iPEC hold out samples and independent PEARL PEC samples (N=10). FIG. 36C is a heatmap of the relative transcript abundance in the iPEC cohort for the genes used by AdaBoost model. The graph on the right indicates how many cross-validation models a given transcript appeared in. FIG. 36D shows concordance of transcripts identified by differential analysis and AdaBoost. FIG. 36E shows tissue expressing elevated levels of transcripts selected by AdaBoost models.

FIGS. 37A and 37B. The C-RNA sample preparation workflow. FIG. 37A shows the approach used for sequencing library preparation. Blood is shipped overnight prior to plasma processing and nucleic acid extraction. cfDNA is digested with Dnase, then cDNA is synthesized from all RNA. Whole transcriptome enrichment is performed prior to sequencing. In FIG. 37B, three methods were assessed for C-RNA transcriptome analyses. rRNA depletion did not consistently enrich the exonic C-RNA fraction; many libraries contain numerous unaligned reads. Likewise, rRNA overwhelmed sequencing datasets when not removed. Enrichment generated libraries with the highest proportion of reads from exonic C-RNA. For all bar graphs, orange shows reads aligned to the human genome, gray shows reads aligned to an rRNA sequence, and pink shows reads that do not align to the human genome (including both non-human RNA and low quality sequences).

FIGS. 38A-38C. The effect of plasma volume on C-RNA data quality. FIG. 38A shows the C-RNA yield in plasma from 122 samples was quantified with the Quant-iT RiboGreen assay (Thermo Fisher). Measurements from 23 samples were below the detection threshold and are excluded from the graph. Bars show mean±SD from 2 technical replicates. Data from 9 independent experiments was used for a meta-analysis evaluating the effect of plasma input on data quality. FIG. 38B shows noise (biological coefficient of variation, edgeR) calculated from biological replicates within each study. FIG. 38C shows library complexity (bound population, preseq) of each sample. ** p<0.01, *** p<0.001 by ANOVA with Tukey's HSD correction, using the study as a blocking variable. 0.5 mL, N=8, 95; 1 mL, N=7, 83; 2 mL, N=7, 33; 4 mL, N=17, 267 for FIGS. 38B and 38C, respectively.

FIGS. 39A-39E. The integrity of C-RNA pregnancy signal after storage in different BCTs. FIG. 39A is a heatmap of the abundance of known C-RNA pregnancy markers after overnight storage in 4 BCTs compared to immediate processing from EDTA BCTs. FIG. 39B shows an integrated measure of pregnancy signal obtained by summing transcript abundance in FIG. 39A discriminates between pregnant and non-pregnant samples. ** p<0.01, *** p<0.001 by ANOVA with Tukey's HSD correction. EDTA immediate, N=4, 8; EDTA overnight, N=7, 7; ACD overnight, N=16, 16; Cell-Free RNA overnight, N=10, 9; Cell-Free DNA overnight, N=8, 8; for non-pregnant and pregnant groups, respectively. FIG. 39C shows correlation of transcriptomic profiles from blood samples collected from the same individual and stored for 0, 1 or 5 days in Cell-free DNA BCTs (Streck, Inc) prior to processing. Bars show mean±range; N=2. The AdaBoost scores assigned to control samples (FIG. 39D) or to PE samples (FIG. 39E) from the iPEC cohort versus the number of days blood was stored at room temperature prior to plasma processing. AdaBoost scores are normalized to range from −1 to +1, with control samples expected to have a score <0, and PE samples to have a score >0. No significant differences in AdaBoost score were observed (ANOVA for controls; T-Test for PE). Control 1 day, N=60; 2 days, N=4; 3 days, N=1, 5 days, N=2. PE 1 day, N=37; 2 days, N=3.

FIGS. 40A-40D. C-RNA transcripts can be altered during specific stages of pregnancy. Dynamic changes in transcripts that primarily change early in pregnancy (FIG. 40A, ˜14 weeks), throughout gestation (FIG. 40B), or predominantly late in pregnancy (FIG. 40C, ˜33 weeks). Note how transcripts which change from the first to second trimester do not return to baseline levels but remain at the altered abundance for the remainder of gestation. FIG. 40D is an ontology and pathway enrichment analysis for transcripts which change during healthy pregnancy. Each filled in box signifies significant enrichment of the corresponding term or pathway. “All Genes” shows analysis of all 156 differentially abundant transcripts. Too few genes were altered late in pregnancy to perform ontological analysis.

FIGS. 41A-41C. Comparing pregnancy-associated transcript tissue specificity for three independent C-RNA studies. FIG. 41A shows tissue specificity for the full set of genes detected in each study. FIG. 41B shows the transcripts unique to each study. FIG. 41C shows intersecting gene sets.

FIGS. 42A and 42B. AdaBoost hyperparameter optimization. Performance, measured by Matthew's Correlation Coefficient, versus the number of estimators (FIG. 42A) or the learning rate (FIG. 42B). Each dot shows the average value obtained from 3-fold cross validation during the random search.

FIGS. 43A-43D. AdaBoost training strategy. In FIG. 43A, the training samples are divided into 5 evenly sized subsets, corresponding to five iterations of model construction. For the first iteration, the samples in subset 1 are used for pruning while the samples in subsets 2, 3, 4, and 5 are combined for AdaBoost fitting; for the second iteration the samples in subset 2 are used for pruning while those in subsets 1, 3, 4, and 5 are used for AdaBoost fitting; and so on for the remaining 3 iterations. As shown in FIG. 43B, for each iteration, an AdaBoost model is fit to the “Fitting Samples.” Then the impact of removing genes below an incrementally increasing importance threshold on classification performance is assessed with the “Pruning Samples.” The model with the best performance and fewest genes is retained. In FIG. 43C, the process in FIG. 43B is repeated 10 times for each set of fitting and pruning samples, generating a total of 50 models. In FIG. 43D, estimators from all models are then aggregated into a single AdaBoost ensemble. Feature pruning of the aggregate model is performed to identify the minimal gene set required for optimal classification.

FIGS. 44A-44D. AdaBoost output is significantly impacted by sample selection. FIG. 44A shows classification performance (log-loss) of the individual models generated from each AdaBoost subset (* p<0.05, *** p<0.001 by ANOVA with Tukey's HSD correction; N=10 each). In FIG. 44B, the frequency each transcript was included in one of the 50 separate AdaBoost models. FIG. 44C is a Venn diagram of the transcripts incorporated in each training subset's models. While 5 transcripts are utilized in models from all subsets, 40 are unique to a single subset. FIG. 44D shows the effect of pruning estimators on classification performance (log-loss) for the final, fully aggregated AdaBoost model also shows distinct behavior for each set of samples. These trends are particularly striking when considering that 75% of the data used for fitting AdaBoost models were shared by any two sets of samples used for fitting AdaBoost. Note these data were generated separately from the final machine learning analysis presented in FIG. 41.

The schematic drawings are not necessarily to scale. Like numbers used in the figures may refer to like components. However, it will be understood that the use of a number to refer to a component in a given figure is not intended to limit the component in another figure labeled with the same number. In addition, the use of different numbers to refer to components is not intended to indicate that the different numbered components cannot be the same or similar to other numbered components.

DETAILED DESCRIPTION

Provided herein are signatures of circulating RNA found in the maternal circulation that are specific to preeclampsia and the use of such signatures in noninvasive methods for the diagnosis of preeclampsia and the identification of pregnant women at risk for developing preeclampsia.

While most of the DNA and RNA in the body is located within cells, extracellular nucleic acids can also be found circulating freely in the blood. Circulating RNA, also referred to herein as “C-RNA,” refers to extracellular segments of RNA found in the bloodstream. C-RNA molecules originate predominately from two sources: one, released into the circulation from dying cells undergoing apoptosis, and two, contained within exosomes shed by living cells into the circulation. Exosomes are small membranous vesicles about 30-150 nm of diameter released from many cell types into the extracellular space and are found in a wide variety of body fluids, including serum, urine, and breast milk and carrying protein, mRNA, and microRNA. The lipid bilayer structure of exosomes protects the RNAs contained within from degradation by RNases, providing for stability in blood. See, for example, Huang et al., 2013, BMC Genomics; 14:319; And Li et al., 2017, Mol Cancer; 16:145). Evidence is accumulating that exosomes have specialized functions and play a role in such processes as coagulation, intercellular signaling, and waste management (van der Pol et al., 2012, Pharmacol Rev; 64(3):676-705). See, also, Samos et al., 2006, Ann N Y Acad Sci; 1075:165-173; Zernecke et al., 2009, Sci Signal; 2:ra81; Ma et al., 2012, J Exp Clin Cancer Res; 31:38; and Sato-Kuwabara et al., 2015, Int J Oncol; 46:17-27.

With the methods described herein, the C-RNA molecules found in maternal circulation function as biomarkers of fetal, placental, and maternal health and provide a window into the progression of pregnancy. Described herein are C-RNA signatures within the maternal circulation that are indicative of pregnancy, C-RNA signatures within the maternal circulation that are temporally associated with the gestational stage of pregnancy, and C-RNA signatures within the maternal circulation that are indicative of the pregnancy complication preeclampsia.

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a plurality of proteins selected from ARRDC2, JUN, SKIL, ATP13A3, PDE8B, GSTA3, PAPPA2, TIPARP, LEP, RGP1, USP54, CLEC4C, MRPS35, ARHGEF25, CUX2, HEATR9, FSTL3, DDI2, ZMYM6, ST6GALNAC3, GBP2, NES, ETV3, ADAM17, ATOH8, SLC4A3, TRAF3IP1, TTC21A, HEG1, ASTE1, TMEM108, ENC1, SCAMP1, ARRDC3, SLC26A2, SLIT3, CLIC5, TNFRSF21, PPP1R17, TPST1, GATSL2, SPDYE5, HIPK2, MTRNR2L6, CLCN1, GINS4, CRH, C10orf2, TRUB1, PRG2, ACY3, FAR2, CD63, CKAP4, TPCN1, RNF6, THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3, SERPINF1, TMEM11, PSMD11, EBI3, CLEC4M, CCDC151, CPAMD8, CNFN, LILRA4, ADA, C22orf39, PI4KAP1, and ARFGAP3. This C-RNA signature is the Adaboost General signature obtained with the TruSeq library prep method shown in Table 1 below, also referred to herein as “list (a)” or “(a).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a plurality of proteins selected from TIMP4, FLG, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, CLEC4C, KRT5, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, and VSIG4. This C-RNA signature is the Bootstrapping signature obtained with the TruSeq library prep method shown in Table 1 below, also referred to herein as “list (b)” or “(b).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from CYP26B1, IRF6, MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366, ADCY1, C6, FAM219A, HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2, SULT2A1, FMO3, FSTL3, GATA5, HTRA1, C8B, H19, MN1, NFE2L1, PRDM16, AP3B2, EMP1, FLNC, STAG3, CPB2, TENC1, RP1L1, A1CF, NPR1, TEK, ERRFI1, ARHGEF15, CD34, RSPO3, ALPK3, SAMD4A, ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16, SERPINA3, AQP7, SRPX, UACA, ANO1, FKBPS, SCN5A, PTPN21, CACNA1C, ERG, SOX17, WWTR1, AIF1L, CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO, FN1, GPR116, KRT17, AZGP1, BCL6B, KIF1C, CLIC5, GPR4, GJA5, OLAH, C14orf37, ZEB1, JAG2, KIF26A, APOLD1, PNMT, MYOM3, PITPNM3, TIMP4, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, VSIG4, HBG2, CADM2, LAMPS, PTGDR2, NOMO1, NXF3, PLD4, BPIFB3, PACSIN1, CUX2, FLG, CLEC4C, and KRT5. This C-RNA signature is the Standard DEX Treat signature obtained with the TruSeq library prep method shown in Table 1 below, also referred to herein as “list (c)” or “(c).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from VSIG4, ADAMTS2, NES, FAM107A, LEP, DAAM2, ARHGEF25, TIMP3, PRX, ALOX15B, HSPA12B, IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1, SEMA3G, KRT5, AMPH, PRG2, PAPPA2, TEAD4, CRH, PITPNM3, TIMP4, PNMT, ZEB1, APOLD1, PLD4, CUX2, and HTRA4. This C-RNA signature is the Jacknifing signature obtained with the TruSeq library prep method shown in Table 1 below, also referred to herein as “list (d)” or “(d).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from ADAMTS1, ADAMTS2, ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2, FAM107A, HSPA12B, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PACSIN1, PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4. This C-RNA signature is the Standard DEX Treat signature obtained with the Nextera Flex for Enrichment library prep method shown in Table 1 below, also referred to herein as “list (e)” or “(e).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25, CELF4, DAAM2, FAM107A, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, and VSIG4. This C-RNA signature is the Jacknifing signature obtained with the Nextera Flex for Enrichment library prep method shown in Table 1 below, also referred to herein as “list (f)” or “(f).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from CLEC4C, ARHGEF25, ADAMTS2, LEP, ARRDC2, SKIL, PAPPA2, VSIG4, ARRDC4, CRH, and NES.

This C-RNA signature is the Adaboost Refined TruSeq signature obtained with the TruSeq library prep method shown in Table 1 below, also referred to herein as “AdaBoost Refined 1,” “list (g),” or “(g).”

In some embodiments, a C-RNA signature within the maternal circulation indicative of preeclampsia includes C-RNA molecules encoding at least a portion of a protein selected from ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, and VSIG4 (also referred to herein as “AdaBoost Refined 2”), ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, SKIL, and VSIG4 (also referred to herein as “AdaBoost Refined 3”), ADAMTS2, ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, and VSIG4 (also referred to herein as “AdaBoost Refined 4”), ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, PAPPA2, SKIL, and VSIG4 (also referred to herein as “AdaBoost Refined 5”), ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, and SKIL (also referred to herein as “AdaBoost Refined 6”), or ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, and SKIL (also referred to herein as “AdaBoost Refined 7”).

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from LEP, PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3, ARHGEF25, ADA, HTRA4, NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1, SERPINF1, SKIL, SEMA3G, TIPARP, LRRC26, PHEX, LILRA4, and PER1. This C-RNA signature is the Adaboost Refined Nextera Flex signature obtained with the Nextera Flex for Enrichment library prep method shown in Table 1 below, also referred to herein as “list (h)” or “(h).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from any of those shown Table S9 of Example 7, also referred to herein as “list (i)” or “(i).”

A C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768, also referred to herein as “list (j)” or “(j).”

In some embodiments, a C-RNA signature within the maternal circulation indicative of preeclampsia includes a plurality of C-RNA molecules encoding at least a portion of a protein selected from of any one or more of any of (a), (b), (c), (d), (e), (f), (g), (h), (i), and/or (j) in combination with any one or more of any of (a), (b), (c), (d), (e), (f), (g), (h), (i), and/or (j).

The Examples provided herewith describe the eight gene lists summarized above that distinguish preeclampsia and control pregnancies. Each was identified by using different analysis methods and/or distinct datasets. However, there is a high degree of concordance between many of these gene sets. Identifying a transcript as altered in preeclampsia C-RNA with multiple approaches indicates that said transcript has higher predictive value for classification of this disease. Thus, the importance of the transcripts identified by all differential expression analyses and by all AdaBoost models was combined and ranked. Genes assigned lower ranks are not unimportant or uninformative, but they may be less robust for classification of preeclampsia across cohorts and sample preparations.

First, the transcripts identified when using all differential expression analyses (Standard DEX Treat, bootstrapping and the jackknifing) for both library preparation methods (TruSeq and Nextera Flex for Enrichment) were combined. Table 2 below shows the relative importance for all of the 125 transcripts identified by the different analysis methods. Transcripts identified across every analysis method and both library preparations are the strongest classifiers and assigned an importance ranking of 1. Transcripts that were identified by three or more analysis methods and were detected with both library preparations were given an importance ranking of 2. Transcripts identified by the most stringent analysis method, jackknifing but only one of the library preparations were assigned an importance ranking of 3. Transcripts identified in two of the five analysis methods were given an importance ranking of 4. Transcripts that were only identified in the Standard DEX Treat method, the most broad and inclusive analysis, were given the lowest importance ranking of 5.

Then, the 91 transcripts identified across all AdaBoost models (AdaBoost General and AdaBoost Refined) and both library preparations (Table 3 below) were combined. When generating the refined AdaBoost models for each library preparation, observed slight variations had been observed in the gene set obtained each time a model was built from the same data. This is a natural result of randomness used by AdaBoost to search through the large whole-exome C-RNA data. To obtain a representative list of genes, model building for refined AdaBoost was run a minimum of nine separate times and all genes used by one or more models reported. The percent of models that included each transcript are reported in Table 3 (Frequency Used By AdaBoost). AdaBoost assigns its own “importance” value to each transcript, which reflects how much the abundance of that transcript influences determining whether a sample is from a preeclampsia patient. These AdaBoost importance values were averaged across each refined AdaBoost model a given transcript was used by (Table 3, Average AdaBoost Model Importance).

Transcripts identified across all AdaBoost analyses and library preparations were assigned the highest importance ranking of 1. Transcripts identified in the refined AdaBoost model for a single library preparation method with over 90% frequency used by AdaBoost were assigned an importance ranking of 2. Generally, these transcripts also have higher AdaBoost model importance, consistent with increased predictive capabilities. Transcripts identified in the refined AdaBoost model for a single library preparation method but used by less than 90% of AdaBoost models were assigned an importance ranking of 3. Transcripts identified only in the general AdaBoost model for a single library preparation were given the lowest importance ranking of 4.

Table 2 lists every gene identified by DEX analysis across all analysis approaches and library preps. Rank 1=Transcript identified across every analysis method and library prep method. Rank 2=Transcript identified both library preps, and 3/5 analysis methods. Rank 3=Identified in one library prep method, in jacknifing, are most stringent analysis. Rank 4=identified in 2/5 analyses. And Rank 5=Only identified in Standard DEX Treat method, our most relaxed analysis method.

Table 3 lists every gene identified by Adaboost analysis across both library preps. Rank 1=identified in both library prep methods and the refined adaboost models. Rank 2=Identified in one library prep method, present in refined adaboost model with high model importance and frequency. Rank 3=identified in one library prep method, present in refined adaboost model with medium model importance and frequency. And Rank 4=Identified in one library prep, not present in the refined adaboost model.

Table 4 below is a glossary of all of the various genes recited herein. The information was obtained from the HUGO Gene Nomenclature Committee at the European Bioinformatics Institute.

TABLE 1 Composite Gene Listing Machine Learning Approaches Adaboost Adaboost Refined DIFFERENTIAL EXPRESSION APPROACHES Refined Nextera Flex Standard DEX Jackknifing TruSeq Library Prep: Bootstrapping Jackknifing TREAT Library Prep: Library Prep: Nextera Flex for Library Prep: Library Prep: Library Prep: Nextera Flex Adaboost TruSeq Enrichment Standard DEX TruSeq TruSeq Nextera Flex for Enrichment General Imrpoved model Imrpoved model TREAT Refined Refined for Enrichment Refined subset of Library Prep: building for building for Library Prep: TruSeq subset subset Broadest Standard DEX TruSeq Adaboost, to Adaboost, to Broadest DEX list of Standard of Standard DEX list TREAT for Broadest improve improve unverisal for TST170 DEX TREAT DEX TREAT for Nextera Nextera adaboost unverisal signal signal 122 genes 27 genes 30 genes 26 genes 22 genes 75 genes 11 genes 24 genes FLG FLG VSIG4 ADAMTS1 ADAMTS1 ARHGEF25 CLEC4C LEP KRT5 KRT5 ADAMTS2 ADAMTS2 ADAMTS2 CLEC4C ARHGEF25 PAPPA2 HBG2 CLEC4C NES ALOX15B ALOX15B CRH ADAMTS2 KCNA5 NXF3 TEAD4 FAM107A AMPH ARHGEF25 CUX2 LEP ADAMTS2 CLEC4C SEMA3G LEP ARHGEF25 CELF4 LEP ARRDC2 MYOM3 BPIFB3 ADAMTS1 DAAM2 CELF4 DAAM2 NES SKIL ATP13A3 LAMP5 IGFBP5 ARHGEF25 DAAM2 FAM107A PAPPA2 PAPPA2 ARHGEF25 CADM2 HSPA12B TIMP3 FAM107A HTRA4 PRG2 VSIG4 ADA CUX2 SLC9A3R2 PRX HSPA12B IGFBP5 ACY3 ARRDC4 HTRA4 PACSIN1 PRX ALOX15B HTRA4 KCNA5 ADA CRH NES PTGDR2 TIMP3 HSPA12B IGFBP5 KRT5 ADAM17 NES CRH PLD4 ARHGEF25 IGFBP5 KCNA5 LCN6 ARFGAP3 ACY3 NOMO1 HTRA4 CLEC4C KRT5 LEP ARRDC2 PLD4 SH3RF2 NES SLC9A3R2 LCN6 LRRC26 ARRDC3 SCT ZNF366 TIMP4 ADAMTS1 LEP NES ASTE1 NOX4 SH3PXD2A PAPPA2 SEMA3G LRRC26 OLAH ATOH8 PACSIN1 SULT2A1 FAM107A KRT5 NES PRX ATP13A3 SERPINF1 FAM219A PRG2 AMPH OLAH PTGDR2 C10orf2 SKIL PPP1R3C AMPH PRG2 PACSIN1 SEMA3G C22orf39 SEMA3G NFE2L1 DAAM2 PAPPA2 PAPPA2 SLC9A3R2 CCDC151 TIPARP PODXL LCN6 TEAD4 PRX TIMP3 CD63 LRRC26 HTRA1 ALOX15B CRH PTGDR2 VSIG4 CKAP4 PHEX EMP1 CRH PITPNM3 SEMA3G CLCN1 LILRA4 H19 VSIG4 TIMP4 SLC9A3R2 CLEC4M PER1 IGIP LEP PNMT TIMP3 CLIC5 SSUH2 ADAMTS2 ZEB1 VSIG4 CNFN C6 ARMS2 APOLD1 CPAMD8 ARHGEF15 PLD4 DDI2 IRF6 CUX2 EBI3 NPR1 HTRA4 ELMO3 ALPK3 ENC1 ZCCHC24 ETV3 SAMD4A FAR2 STAG3 FOS RP1L1 FSTL3 A1CF GATSL2 MN1 GBP2 CD34 GINS4 MYH14 GSTA3 TENC1 HEATR9 FSTL3 HEG1 PRDM16 HIPK2 FMO3 JUN UACA LILRA4 TEK MRPS35 SOX17 MTRNR2L6 FLNC ORAI3 TMC7 PARN KIF1C PDE8B CLIC5 PI4KAP1 SYNPO PPP1R17 CACNA1C PSMD11 ERG RGP1 PTPN21 RNF6 NTRK2 SCAMP1 WWTR1 SERPINF1 CYP26B1 SKIL ZEB1 SLC26A2 AIF1L SLC4A3 C8B SLIT3 KIF26A SMPD3 ZBTB16 SPDYE5 BCL6B ST6GALNAC3 FKBP5 THTPA FN1 TIPARP AQP7 TMEM108 IL1R2 TMEM11 ERRFI1 TNFRSF21 SRPX TPCN1 GJA5 TPST1 GPR116 TRAF3IP1 JAG2 TRUB1 MYL2 TTC21A ADCY1 USP54 NRG3 ZMYM6 GPR4 PITPNM3 SERPINA3 CPB2 ADRA2C ANO1 CA3 C14orf37 TEAD4 TAT LEAP2 HAO2 SEMA3G ADAMTS1 APOLD1 IGFBP5 HSPA12B GATA5 SLC9A3R2 RSPO3 AQP7P1 PRX PNMT MYOM3 HRG TIMP3 ARHGEF25 HTRA4 SCN5A OLAH NES TIMP4 PAPPA2 AZGP1 FAM107A PRG2 AMPH AP3B2 KRT17 DAAM2 LCN6 ALOX15B CRH VSIG4 LEP ADAMTS2 ARMS2

TABLE 2 DEX Analysis TruSeq Standard Nextera Flex for enrichment Importance DEX Fold Standard Fold Gene Ranking TREAT Change Bootstrapping Jackknifing DEX Change Jackknifing ADAMTS1 1 Y 1.79 Y Y Y +3.2 Y ADAMTS2 1 Y 3.61 Y Y Y +12.2  Y ALOX15B 1 Y 2.51 Y Y Y +5.3 Y ARHGEF25 1 Y 2.02 Y Y Y +3.8 Y DAAM2 1 Y 2.48 Y Y Y +5.4 Y FAM107A 1 Y 2.31 Y Y Y +4.3 Y HTRA4 1 Y 2.03 Y Y Y +4.0 Y IGFBP5 1 Y 1.81 Y Y Y +3.4 Y KRT5 1 Y −2.52 Y Y Y −4.8 Y LEP 1 Y 3.48 Y Y Y +8.1 Y NES 1 Y 2.15 Y Y Y +4.2 Y PRX 1 Y 1.93 Y Y Y +3.3 Y SEMA3G 1 Y 1.78 Y Y Y +3.5 Y SLC9A3R2 1 Y 1.85 Y Y Y +3.4 Y TIMP3 1 Y 2.01 Y Y Y +3.7 Y VSIG4 1 Y 3.03 Y Y Y +8.2 Y PAPPA2 2 Y 2.20 Y Y Y +4.2 N AMPH 2 Y 2.37 Y Y Y +4.1 N HSPA12B 2 Y 1.82 Y Y Y +3.2 N PTGDR2 2 Y −1.67 N N Y −3.5 Y LCN6 2 Y 2.49 Y N Y +4.4 Y OLAH 2 Y 2.07 N N Y +5.2 Y APOLD1 3 Y 1.80 N Y N NA N CUX2 3 Y −1.73 N Y N NA N PITPNM3 3 Y 1.66 N Y N NA N PLD4 3 Y −1.59 N Y N NA N PNMT 3 Y 1.98 N Y N NA N CLEC4C 3 Y −1.86 Y Y N NA N CRH 3 Y 2.54 Y Y N NA N PRG2 3 Y 2.36 Y Y N NA N TEAD4 3 Y 1.74 Y Y N NA N TIMP4 3 Y 2.17 Y Y N NA N CELF4 3 N NA N N Y +5.3 Y KCNA5 3 N NA N N Y −4.0 Y LRRC26 3 N NA N N Y −4.4 Y ARMS2 4 Y 4.43 Y N N NA N FLG 4 Y −3.05 Y N N NA N PACSIN1 4 Y −1.70 N N Y −3.4 N A1CF 5 Y 1.37 N N N NA N ADCY1 5 Y 1.62 N N N NA N ADRA2C 5 Y 1.69 N N N NA N AIF1L 5 Y 1.48 N N N NA N ALPK3 5 Y 1.35 N N N NA N ANO1 5 Y 1.69 N N N NA N AP3B2 5 Y 2.40 N N N NA N AQP7 5 Y 1.51 N N N NA N AQP7P1 5 Y 1.88 N N N NA N ARHGEF15 5 Y 1.33 N N N NA N AZGP1 5 Y 2.27 N N N NA N BCL6B 5 Y 1.50 N N N NA N BPIFB3 5 Y −1.80 N N N NA N C14orf37 5 Y 1.73 N N N NA N C6 5 Y 1.33 N N N NA N C8B 5 Y 1.49 N N N NA N CA3 5 Y 1.72 N N N NA N CACNA1C 5 Y 1.42 N N N NA N CADM2 5 Y −1.76 N N N NA N CD34 5 Y 1.37 N N N NA N CLIC5 5 Y 1.41 N N N NA N CPB2 5 Y 1.69 N N N NA N CYP26B1 5 Y 1.48 N N N NA N EMP1 5 Y 1.30 N N N NA N ERG 5 Y 1.43 N N N NA N ERRFI1 5 Y 1.54 N N N NA N FAM219A 5 Y 1.24 N N N NA N FKBP5 5 Y 1.50 N N N NA N FLNC 5 Y 1.40 N N N NA N FMO3 5 Y 1.39 N N N NA N FN1 5 Y 1.51 N N N NA N FSTL3 5 Y 1.38 N N N NA N GATA5 5 Y 1.82 N N N NA N GJA5 5 Y 1.55 N N N NA N GPR116 5 Y 1.56 N N N NA N GPR4 5 Y 1.65 N N N NA N H19 5 Y 1.32 N N N NA N HAO2 5 Y 1.75 N N N NA N HBG2 5 Y −2.15 N N N NA N HRG 5 Y 1.99 N N N NA N HTRA1 5 Y 1.29 N N N NA N IGIP 5 Y 1.32 N N N NA N IL1R2 5 Y 1.53 N N N NA N IRF6 5 Y 1.34 N N N NA N JAG2 5 Y 1.57 N N N NA N KIF1C 5 Y 1.41 N N N NA N KIF26A 5 Y 1.49 N N N NA N KRT17 5 Y 2.47 N N N NA N LAMP5 5 Y −1.77 N N N NA N LEAP2 5 Y 1.74 N N N NA N MN1 5 Y 1.37 N N N NA N MYH14 5 Y 1.38 N N N NA N MYL2 5 Y 1.60 N N N NA N MYOM3 5 Y 1.99 N N N NA N NFE2L1 5 Y 1.26 N N N NA N NOMO1 5 Y −1.49 N N N NA N NPR1 5 Y 1.34 N N N NA N NRG3 5 Y 1.62 N N N NA N NTRK2 5 Y 1.45 N N N NA N NXF3 5 Y −1.96 N N N NA N PODXL 5 Y 1.27 N N N NA N PPP1R3C 5 Y 1.25 N N N NA N PRDM16 5 Y 1.38 N N N NA N PTPN21 5 Y 1.44 N N N NA N RP1L1 5 Y 1.36 N N N NA N RSPO3 5 Y 1.87 N N N NA N SAMD4A 5 Y 1.35 N N N NA N SCN5A 5 Y 2.03 N N N NA N SERPINA3 5 Y 1.67 N N N NA N SH3PXD2A 5 Y 1.23 N N N NA N SH3RF2 5 Y 1.18 N N N NA N SOX17 5 Y 1.40 N N N NA N SRPX 5 Y 1.55 N N N NA N SSUH2 5 Y 1.33 N N N NA N STAG3 5 Y 1.36 N N N NA N SULT2A1 5 Y 1.23 N N N NA N SYNPO 5 Y 1.42 N N N NA N TAT 5 Y 1.74 N N N NA N TEK 5 Y 1.39 N N N NA N TENC1 5 Y 1.38 N N N NA N TMC7 5 Y 1.40 N N N NA N UACA 5 Y 1.39 N N N NA N WWTR1 5 Y 1.47 N N N NA N ZBTB16 5 Y 1.50 N N N NA N ZCCHC24 5 Y 1.35 N N N NA N ZEB1 5 Y 1.48 N Y N NA N ZNF366 5 Y 1.23 N N N NA N

TABLE 3 Adaboost Analysis Fold Change in Frequency Used By Average AdaBoost Model Importance Preeclampsia Adaboost Importance Ranking TruSeq Nextera Flex TruSeq Nextera Flex TruSeq Nextera Flex ADAMTS2 1 +11.6  +12.2  100%  100% 9% 8% ARHGEF25 1 +4.1 +3.8 100%  100% 11%  5% CRH 1 +5.7 +3.9 14% 100% 2% 4% LEP 1 +10.7  +8.1 100%  100% 8% 17%  NES 1 +4.5 +4.2  7% 100% 4% 4% PAPPA2 1 +4.9 +4.2 64% 100% 3% 8% SKIL 1 +1.5 +1.4 86%  78% 3% 3% ACY3 2 ND −2.3 ND 100% ND 3% ADA 2 ND −1.6 ND 100% ND 5% ARRDC2 2 +1.8 ND 93% ND 3% ND ATP13A3 2 ND +1.5 ND 100% ND 5% CLEC4C 2 −3.6 ND 100%  ND 18%  ND HTRA4 2 ND +4.0 ND 100% ND 5% KCNA5 2 ND −4.0 ND 100% ND 8% MYOM3 2 ND +4.2 ND 100% ND 7% NOX4 2 ND −1.8 ND 100% ND 2% PACSIN1 2 ND −3.4 ND 100% ND 2% PLD4 2 ND −2.7 ND 100% ND 3% SCT 2 ND −3.3 ND 100% ND 3% SERPINF1 2 ND −1.6 ND 100% ND 2% VSIG4 3 +8.1 ND 43% ND 3% ND ARRDC4 3 +2.0 ND 36% ND 4% ND LILRA4 3 ND −2.7 ND  33% ND 1% LRRC26 3 ND −4.4 ND  56% ND 2% PER1 3 ND +2.2 ND  33% ND 1% PHEX 3 ND −2.2 ND  56% ND 2% SEMA3G 3 ND +3.5 ND  67% ND 5% TIPARP 3 ND +1.2 ND  67% ND 2% ADAM17 4 ND ND ND ND ND ND ARFGAP3 4 ND ND ND ND ND ND ARRDC3 4 ND ND ND ND ND ND ASTE1 4 ND ND ND ND ND ND ATOH8 4 ND ND ND ND ND ND C10orf2 4 ND ND ND ND ND ND C22orf39 4 ND ND ND ND ND ND CCDC151 4 ND ND ND ND ND ND CD63 4 ND ND ND ND ND ND CKAP4 4 ND ND ND ND ND ND CLCN1 4 ND ND ND ND ND ND CLEC4M 4 ND ND ND ND ND ND CLIC5 4 ND ND ND ND ND ND CNFN 4 ND ND ND ND ND ND CPAMD8 4 ND ND ND ND ND ND CUX2 4 ND ND ND ND ND ND DDI2 4 ND ND ND ND ND ND EBI3 4 ND ND ND ND ND ND ELMO3 4 ND ND ND ND ND ND ENC1 4 ND ND ND ND ND ND ETV3 4 ND ND ND ND ND ND FAR2 4 ND ND ND ND ND ND FOS 4 ND ND ND ND ND ND FSTL3 4 ND ND ND ND ND ND GATSL2 4 ND ND ND ND ND ND GBP2 4 ND ND ND ND ND ND GINS4 4 ND ND ND ND ND ND GSTA3 4 ND ND ND ND ND ND HEATR9 4 ND ND ND ND ND ND HEG1 4 ND ND ND ND ND ND HIPK2 4 ND ND ND ND ND ND JUN 4 ND ND ND ND ND ND MRPS35 4 ND ND ND ND ND ND MTRNR2L6 4 ND ND ND ND ND ND ORAI3 4 ND ND ND ND ND ND PARN 4 ND ND ND ND ND ND PDE8B 4 ND ND ND ND ND ND PI4KAP1 4 ND ND ND ND ND ND PPP1R17 4 ND ND ND ND ND ND PRG2 4 ND ND ND ND ND ND PSMD11 4 ND ND ND ND ND ND RGP1 4 ND ND ND ND ND ND RNF6 4 ND ND ND ND ND ND SCAMP1 4 ND ND ND ND ND ND SLC26A2 4 ND ND ND ND ND ND SLC4A3 4 ND ND ND ND ND ND SLIT3 4 ND ND ND ND ND ND SMPD3 4 ND ND ND ND ND ND SPDYE5 4 ND ND ND ND ND ND ST6GALNAC3 4 ND ND ND ND ND ND THTPA 4 ND ND ND ND ND ND TMEM108 4 ND ND ND ND ND ND TMEM11 4 ND ND ND ND ND ND TNFRSF21 4 ND ND ND ND ND ND TPCN1 4 ND ND ND ND ND ND TPST1 4 ND ND ND ND ND ND TRAF3IP1 4 ND ND ND ND ND ND TRUB1 4 ND ND ND ND ND ND TTC21A 4 ND ND ND ND ND ND USP54 4 ND ND ND ND ND ND ZMYM6 4 ND ND ND ND ND ND

TABLE 4 Gene Glossary Gene Symbol Used Official Gene in Patent Symbol Approved Name HGNC ID Location KRT5 KRT5 keratin 5 HGNC:6442 12q13.13 CUX2 CUX2 cut like homeobox 2 HGNC:19347 12q24.11-q24.12 CLEC4C CLEC4C C-type lectin domain family 4 member C HGNC:13258 12p13.31 PLD4 PLD4 phospholipase D family member 4 HGNC:23792 14q32.33 ALOX15B ALOX15B arachidonate 15-lipoxygenase type B HGNC:434 17p13.1 PRG2 PRG2 proteoglycan 2, pro eosinophil major basic protein HGNC:9362 11q12.1 HTRA4 HTRA4 HtrA serine peptidase 4 HGNC:26909 8p11.22 AMPH AMPH amphiphysin HGNC:471 7p14.1 PNMT PNMT phenylethanolamine N-methyltransferase HGNC:9160 17q12 LEP LEP leptin HGNC:6553 7q32.1 PAPPA2 PAPPA2 pappalysin 2 HGNC:14615 1q25.2 CRH CRH corticotropin releasing hormone HGNC:2355 8q13.1 TIMP4 TIMP4 TIMP metallopeptidase inhibitor 4 HGNC:11823 3p25.2 APOLD1 APOLD1 apolipoprotein L domain containing 1 HGNC:25268 12p13.1 ARHGEF25 ARHGEF25 Rho guanine nucleotide exchange factor 25 HGNC:30275 12q13.3 TIMP3 TIMP3 TIMP metallopeptidase inhibitor 3 HGNC:11822 22q12.3 SEMA3G SEMA3G semaphorin 3G HGNC:30400 3p21.1 IGFBP5 IGFBP5 insulin like growth factor binding protein 5 HGNC:5474 2q35 PRX PRX periaxin HGNC:13797 19q13.2 PITPNM3 PITPNM3 PITPNM family member 3 HGNC:21043 17p13.2-p13.1 FAM107A FAM107A family with sequence similarity 107 member A HGNC:30827 3p14.3-p14.2 TEAD4 TEAD4 TEA domain transcription factor 4 HGNC:11717 12p13.33 HSPA12B HSPA12B heat shock protein family A (Hsp70) member 12B HGNC:16193 20p13 NES NES nestin HGNC:7756 1q23.1 SLC9A3R2 SLC9A3R2 SLC9A3 regulator 2 HGNC:11076 16p13.3 ZEB1 ZEB1 zinc finger E-box binding homeobox 1 HGNC:11642 10p11.22 ADAMTS1 ADAMTS1 ADAM metallopeptidase with thrombospondin type 1 motif 1 HGNC:217 21q21.3 DAAM2 DAAM2 dishevelled associated activator of morphogenesis 2 HGNC:18143 6p21.2 ADAMTS2 ADAMTS2 ADAM metallopeptidase with thrombospondin type 1 motif 2 HGNC:218 5q35.3 VSIG4 VSIG4 V-set and immunoglobulin domain containing 4 HGNC:17032 Xq12 ARRDC2 ARRDC2 arrestin domain containing 2 HGNC:25225 19p13.11 SKIL SKIL SKI like proto-oncogene HGNC:10897 3q26.2 ARRDC4 ARRDC4 arrestin domain containing 4 HGNC:28087 15q26.2 KCNA5 KCNA5 potassium voltage-gated channel subfamily A member 5 HGNC:6224 12p13.32 MYOM3 MYOM3 myomesin 3 HGNC:26679 1p36.11 ATP13A3 ATP13A3 ATPase 13A3 HGNC:24113 3q29 ADA ADA adenosine deaminase HGNC:186 20q13.12 ACY3 ACY3 aminoacylase 3 HGNC:24104 11q13.2 SCT SCT secretin HGNC:10607 11p15.5 NOX4 NOX4 NADPH oxidase 4 HGNC:7891 11q14.3 PACSIN1 PACSIN1 protein kinase C and casein kinase substrate in neurons 1 HGNC:8570 6p21.3 SERPINF1 SERPINF1 serpin family F member 1 HGNC:8824 17p13.3 TIPARP TIPARP TCDD inducible poly(ADP-ribose) polymerase HGNC:23696 3q25.31 LRRC26 LRRC26 leucine rich repeat containing 26 HGNC:31409 9q34.3 PHEX PHEX phosphate regulating endopeptidase homolog X-linked HGNC:8918 Xp22.11 LILRA4 LILRA4 leukocyte immunoglobulin like receptor A4 HGNC:15503 19q13.42 PER1 PER1 period circadian regulator 1 HGNC:8845 17p13.1 CELF4 CELF4 CUGBP Elav-like family member 4 HGNC:14015 18q12.2 LCN6 LCN6 lipocalin 6 HGNC:17337 9q34.3 OLAH OLAH oleoyl-ACP hydrolase HGNC:25625 10p13 PTGDR2 PTGDR2 prostaglandin D2 receptor 2 HGNC:4502 11q12.2 JUN JUN Jun proto-oncogene, AP-1 transcription factor subunit HGNC:6204 1p32.1 PDE8B PDE8B phosphodiesterase 8B HGNC:8794 5q13.3 GSTA3 GSTA3 glutathione S-transferase alpha 3 HGNC:4628 6p12.2 RGP1 RGP1 RGP1 homolog, RAB6A GEF complex partner 1 HGNC:21965 9p13.3 USP54 USP54 ubiquitin specific peptidase 54 HGNC:23513 10q22.2 MRPS35 MRPS35 mitochondrial ribosomal protein S35 HGNC:16635 12p11.22 HEATR9 HEATR9 HEAT repeat containing 9 HGNC:26548 17q12 FSTL3 FSTL3 follistatin like 3 HGNC:3973 19p13.3 DDI2 DDI2 DNA damage inducible 1 homolog 2 HGNC:24578 1p36.21 ZMYM6 ZMYM6 zinc finger MYM-type containing 6 HGNC:13050 1p34.3 ST6GALNAC3 ST6GALNAC3 ST6 N-acetylgalactosaminide alpha-2,6-sialyltransferase 3 HGNC:19343 1p31.1 GBP2 GBP2 guanylate binding protein 2 HGNC:4183 1p22.2 ETV3 ETV3 ETS variant 3 HGNC:3492 1q23.1 ADAM17 ADAM17 ADAM metallopeptidase domain 17 HGNC:195 2p25.1 ATOH8 ATOH8 atonal bHLH transcription factor 8 HGNC:24126 2p11.2 SLC4A3 SLC4A3 solute carrier family 4 member 3 HGNC:11029 2q35 TRAF3IP1 TRAF3IP1 TRAF3 interacting protein 1 HGNC:17861 2q37.3 TTC21A TTC21A tetratricopeptide repeat domain 21A HGNC:30761 3p22.2 HEG1 HEG1 heart development protein with EGF like domains 1 HGNC:29227 3q21.2 ASTE1 ASTE1 asteroid homolog 1 HGNC:25021 3q22.1 TMEM108 TMEM108 transmembrane protein 108 HGNC:28451 3q22.1 ENC1 ENC1 ectodermal-neural cortex 1 HGNC:3345 5q13.3 SCAMP1 SCAMP1 secretory carrier membrane protein 1 HGNC:10563 5q14.1 ARRDC3 ARRDC3 arrestin domain containing 3 HGNC:29263 5q14.3 SLC26A2 SLC26A2 solute carrier family 26 member 2 HGNC:10994 5q32 SLIT3 SLIT3 slit guidance ligand 3 HGNC:11087 5q34-q35.1 CLIC5 CLIC5 chloride intracellular channel 5 HGNC:13517 6p21.1 TNFRSF21 TNFRSF21 TNF receptor superfamily member 21 HGNC:13469 6p12.3 PPP1R17 PPP1R17 protein phosphatase 1 regulatory subunit 17 HGNC:16973 7p14.3 TPST1 TPST1 tyrosylprotein sulfotransferase 1 HGNC:12020 7q11.21 GATSL2 CASTOR2 cytosolic arginine sensor for mTORC1 subunit 2 HGNC:37073 7q11.23 SPDYE5 SPDYE5 speedy/RINGO cell cycle regulator family member E5 HGNC:35464 7q11.23 HIPK2 HIPK2 homeodomain interacting protein kinase 2 HGNC:14402 7q34 MTRNR2L6 MTRNR2L6 MT-RNR2 like 6 HGNC:37163 7q34 CLCN1 CLCN1 chloride voltage-gated channel 1 HGNC:2019 7q34 GINS4 GINS4 GINS complex subunit 4 HGNC:28226 8p11.21 C10orf2 TWNK twinkle mtDNA helicase HGNC:1160 10q24.31 TRUB1 TRUB1 TruB pseudouridine synthase family member 1 HGNC:16060 10q25.3 FAR2 FAR2 fatty acyl-CoA reductase 2 HGNC:25531 12p11.22 CD63 CD63 CD63 molecule HGNC:1692 12q13.2 CKAP4 CKAP4 cytoskeleton associated protein 4 HGNC:16991 12q23.3 TPCN1 TPCN1 two pore segment channel 1 HGNC:18182 12q24.13 RNF6 RNF6 ring finger protein 6 HGNC:10069 13q12.13 THTPA THTPA thiamine triphosphatase HGNC:18987 14q11.2 FOS FOS Fos proto-oncogene, AP-1 transcription factor subunit HGNC:3796 14q24.3 PARN PARN poly(A)-specific ribonuclease HGNC:8609 16p13.12 ORAI3 ORAI3 ORAI calcium release-activated calcium modulator 3 HGNC:28185 16p11.2 ELMO3 ELMO3 engulfment and cell motility 3 HGNC:17289 16q22.1 SMPD3 SMPD3 sphingomyelin phosphodiesterase 3 HGNC:14240 16q22.1 TMEM11 TMEM11 transmembrane protein 11 HGNC:16823 17p11.1 PSMD11 PSMD11 proteasome 26S subunit, non-ATPase 11 HGNC:9556 17q11.2 EBI3 EBI3 Epstein-Barr virus induced 3 HGNC:3129 19p13.3 CLEC4M CLEC4M C-type lectin domain family 4 member M HGNC:13523 19p13.2 CCDC151 CCDC151 coiled-coil domain containing 151 HGNC:28303 19p13.2 CPAMD8 CPAMD8 C3 and PZP like alpha-2-macroglobulin domain containing 8 HGNC:23228 19p13.11 CNFN CNFN cornifelin HGNC:30183 19q13.2 C22orf39 C22orf39 chromosome 22 open reading frame 39 HGNC:27012 22q11.21 PI4KAP1 PI4KAP1 phosphatidylinositol 4-kinase alpha pseudogene 1 HGNC:33576 22q11.21 ARFGAP3 ARFGAP3 ADP ribosylation factor GTPase activating protein 3 HGNC:661 22q13.2 FLG FLG filaggrin HGNC:3748 1q21.3 ARMS2 ARMS2 age-related maculopathy susceptibility 2 HGNC:32685 10q26.13 CYP26B1 CYP26B1 cytochrome P450 family 26 subfamily B member 1 HGNC:20581 2p13.2 IRF6 IRF6 interferon regulatory factor 6 HGNC:6121 1q32.2 MYH14 MYH14 myosin heavy chain 14 HGNC:23212 19q13.33 PODXL PODXL podocalyxin like HGNC:9171 7q32.3 PPP1R3C PPP1R3C protein phosphatase 1 regulatory subunit 3C HGNC:9293 10q23.32 SH3RF2 SH3RF2 SH3 domain containing ring finger 2 HGNC:26299 5q32 TMC7 TMC7 transmembrane channel like 7 HGNC:23000 16p12.3 ZNF366 ZNF366 zinc finger protein 366 HGNC:18316 5q13.1 ADCY1 ADCY1 adenylate cyclase 1 HGNC:232 7p12.3 C6 C6 complement C6 HGNC:1339 5p13.1 FAM219A FAM219A family with sequence similarity 219 member A HGNC:19920 9p13.3 HAO2 HAO2 hydroxyacid oxidase 2 HGNC:4810 1p12 IGIP IGIP IgA inducing protein HGNC:33847 5q31.3 IL1R2 IL1R2 interleukin 1 receptor type 2 HGNC:5994 2q11.2 NTRK2 NTRK2 neurotrophic receptor tyrosine kinase 2 HGNC:8032 9q21.33 SH3PXD2A SH3PXD2A SH3 and PX domains 2A HGNC:23664 10q24.33 SSUH2 SSUH2 ssu-2 homolog HGNC:24809 3p25.3 SULT2A1 SULT2A1 sulfotransferase family 2A member 1 HGNC:11458 19q13.33 FMO3 FMO3 flavin containing dimethylaniline monoxygenase 3 HGNC:3771 1q24.3 GATA5 GATA5 GATA binding protein 5 HGNC:15802 20q13.33 HTRA1 HTRA1 HtrA serine peptidase 1 HGNC:9476 10q26.13 C8B C8B complement C8 beta chain HGNC:1353 1p32.2 H19 H19 H19 imprinted maternally expressed transcript HGNC:4713 11p15.5 MN1 MN1 MN1 proto-oncogene, transcriptional regulator HGNC:7180 22q12.1 NFE2L1 NFE2L1 nuclear factor, erythroid 2 like 1 HGNC:7781 17q21.3 PRDM16 PRDM16 PR/SET domain 16 HGNC:14000 1p36.32 AP3B2 AP3B2 adaptor related protein complex 3 subunit beta 2 HGNC:567 15q25.2 EMP1 EMP1 epithelial membrane protein 1 HGNC:3333 12p13.1 FLNC FLNC filamin C HGNC:3756 7q32.1 STAG3 STAG3 stromal antigen 3 HGNC:11356 7q22.1 CPB2 CPB2 carboxypeptidase B2 HGNC:2300 13q14.13 TENC1 TNS2 tensin 2 HGNC:19737 12q13.13 RP1L1 RP1L1 RP1 like 1 HGNC:15946 8p23.1 A1CF A1CF APOBEC1 complementation factor HGNC:24086 10q11.23 NPR1 NPR1 natriuretic peptide receptor 1 HGNC:7943 1q21.3 TEK TEK TEK receptor tyrosine kinase HGNC:11724 9p21.2 ERRFI1 ERRFI1 ERBB receptor feedback inhibitor 1 HGNC:18185 1p36.23 ARHGEF15 ARHGEF15 Rho guanine nucleotide exchange factor 15 HGNC:15590 17p13.1 CD34 CD34 CD34 molecule HGNC:1662 1q32.2 RSPO3 RSPO3 R-spondin 3 HGNC:20866 6q22.33 ALPK3 ALPK3 alpha kinase 3 HGNC:17574 15q25.3 SAMD4A SAMD4A sterile alpha motif domain containing 4A HGNC:23023 14q22.2 ZCCHC24 ZCCHC24 zinc finger CCHC-type containing 24 HGNC:26911 10q22.3 LEAP2 LEAP2 liver enriched antimicrobial peptide 2 HGNC:29571 5q31.1 MYL2 MYL2 myosin light chain 2 HGNC:7583 12q24.11 NRG3 NRG3 neuregulin 3 HGNC:7999 10q23.1 ZBTB16 ZBTB16 zinc finger and BTB domain containing 16 HGNC:12930 11q23.2 SERPINA3 SERPINA3 serpin family A member 3 HGNC:16 14q32.13 AQP7 AQP7 aquaporin 7 HGNC:640 9p13.3 SRPX SRPX sushi repeat containing protein X-linked HGNC:11309 Xp11.4 UACA UACA uveal autoantigen with coiled-coil domains and ankyrin repeats HGNC:15947 15q23 ANO1 ANO1 anoctamin 1 HGNC:21625 11q13.3 FKBP5 FKBP5 FKBP prolyl isomerase 5 HGNC:3721 6p21.31 SCN5A SCN5A sodium voltage-gated channel alpha subunit 5 HGNC:10593 3p22.2 PTPN21 PTPN21 protein tyrosine phosphatase non-receptor type 21 HGNC:9651 14q31.3 CACNA1C CACNA1C calcium voltage-gated channel subunit alpha1 C HGNC:1390 12p13.33 ERG ERG ETS transcription factor ERG HGNC:3446 21q22.2 SOX17 SOX17 SRY-box 17 HGNC:18122 8q11.23 WWTR1 WWTR1 WW domain containing transcription regulator 1 HGNC:24042 3q25.1 AIF1L AIF1L allograft inflammatory factor 1 like HGNC:28904 9q34.12-q34.13 CA3 CA3 carbonic anhydrase 3 HGNC:1374 8q21.2 HRG HRG histidine rich glycoprotein HGNC:5181 3q27.3 TAT TAT tyrosine aminotransferase HGNC:11573 16q22.2 AQP7P1 AQP7P1 aquaporin 7 pseudogene 1 HGNC:32048 9q13 ADRA2C ADRA2C adrenoceptor alpha 2C HGNC:283 4p16.3 SYNPO SYNPO synaptopodin HGNC:30672 5q33.1 FN1 FN1 fibronectin 1 HGNC:3778 2q35 GPR116 ADGRF5 adhesion G protein-coupled receptor F5 HGNC:19030 6p12.3 KRT17 KRT17 keratin 17 HGNC:6427 17q21.2 AZGP1 AZGP1 alpha-2-glycoprotein 1, zinc-binding HGNC:910 7q22.1 BCL6B BCL6B BCL6B transcription repressor HGNC:1002 17p13.1 KIF1C KIF1C kinesin family member 1C HGNC:6317 17p13.2 GPR4 GPR4 G protein-coupled receptor 4 HGNC:4497 19q13.32 GJA5 GJA5 gap junction protein alpha 5 HGNC:4279 1q21.2 C14orf37 ARMH4 armadillo like helical domain containing 4 HGNC:19846 14q23.1 JAG2 JAG2 jagged canonical Notch ligand 2 HGNC:6189 14q32.33 KIF26A KIF26A kinesin family member 26A HGNC:20226 14q32.33 HBG2 HBG2 hemoglobin subunit gamma 2 HGNC:4832 11p15.4 CADM2 CADM2 cell adhesion molecule 2 HGNC:29849 3p12.1 LAMP5 LAMP5 lysosomal associated membrane protein family member 5 HGNC:16097 20p12.2 NOMO1 NOMO1 NODAL modulator 1 HGNC:30060 16p13.11 NXF3 NXF3 nuclear RNA export factor 3 HGNC:8073 Xq22.1 BPIFB3 BPIFB3 BPI fold containing family B member 3 HGNC:16178 20q11.21 CGB8 CGB8 chorionic gonadotropin subunit beta 8 HGNC:16453 19q13.33 CGB5 CGB5 chorionic gonadotropin subunit beta 5 HGNC:16452 19q13.33 ZSCAN23 ZSCAN23 zinc finger and SCAN domain containing 23 HGNC:21193 6p22.1 HSPA1A HSPA1A heat shock protein family A (Hsp70) member 1A HGNC:5232 6p21.33 PMAIP1 PMAIP1 phorbol-12-myristate-13-acetate-induced protein 1 HGNC:9108 18q21.32 C8orf4 TCIM transcriptional and immune response regulator HGNC:1357 8p11.21 ITM2B ITM2B integral membrane protein 2B HGNC:6174 13q14.2 IFIT2 IFIT2 interferon induced protein with tetratricopeptide repeats 2 HGNC:5409 10q23.31 CD74 CD74 CD74 molecule HGNC:1697 5q33.1 HSPA6 HSPA6 heat shock protein family A (Hsp70) member 6 HGNC:5239 1q23.3 TFAP2A TFAP2A transcription factor AP-2 alpha HGNC:11742 6p24.3 TRPV6 TRPV6 transient receptor potential cation channel subfamily V member 6 HGNC:14006 7q34 EXPH5 EXPH5 exophilin 5 HGNC:30578 11q22.3 CAPN6 CAPN6 calpain 6 HGNC:1483 Xq23 ALDH3B2 ALDH3B2 aldehyde dehydrogenase 3 family member B2 HGNC:411 11q13.2 RAB3B RAB3B RAB3B, member RAS oncogene family HGNC:9778 1p32.3 MUC15 MUC15 mucin 15, cell surface associated HGNC:14956 11p14.3 GRHL2 GRHL2 grainyhead like transcription factor 2 HGNC:2799 8q22.3 CSHL1 CSHL1 chorionic somatomammotropin hormone like 1 HGNC:2442 17q23.3 CSH2 CSH2 chorionic somatomammotropin hormone 2 HGNC:2441 17q23.3 KISS1 KISS1 KiSS-1 metastasis suppressor HGNC:6341 1q32.1 CGA CGA glycoprotein hormones, alpha polypeptide HGNC:1885 6q14.3 PLAC4 PLAC4 p1acenta enriched 4 HGNC:14616 21q22.2 PSG1 PSG1 pregnancy specific beta-1-glycoprotein 1 HGNC:9514 19q13.2 GH2 GH2 growth hormone 2 HGNC:4262 17q23.3 PSG3 PSG3 pregnancy specific beta-1-glycoprotein 3 HGNC:9520 19q13.2 PSG4 PSG4 pregnancy specific beta-1-glycoprotein 4 HGNC:9521 19q13.31 PSG7 PSG7 pregnancy specific beta-1-glycoprotein 7 (gene/pseudogene) HGNC:9524 19q13.31 PSG11 PSG11 pregnancy specific beta-1-glycoprotein 11 HGNC:9516 19q13.31 CSH1 CSH1 chorionic somatomammotropin hormone 1 HGNC:2440 17q23.3 PSG2 PSG2 pregnancy specific beta-1-glycoprotein 2 HGNC:9519 19q13.31 hydroxy-delta-5-steroid dehydrogenase, HSD3B1 HSD3B1 3 beta- and steroid delta-isomerase 1 HGNC:5217 1p12 LGALS14 LGALS14 galectin 14 HGNC:30054 19q13.2 FCGR1C FCGR1CP Fc fragment of IgG receptor Ic, pseudogene HGNC:3615 1q21.1 PSG5 PSG5 pregnancy specific beta-l-glycoprotein 5 HGNC:9522 19q13.31 LAGALS13 LGALS13 galectin 13 HGNC:15449 19q13.2 GCM1 GCM1 glial cells missing transcription factor 1 HGNC:4197 6p12.1

The term “plurality” refers to more than one element. For example, the term is used herein in reference to a number of C-RNA molecules that serve as a signature indicative of preeclampsia.

A plurality may include any two, any three, any four, any five, any six, any seven, any eight, any nine, any ten, any eleven, any twelve, any thirteen, any fourteen, any fifteen, any sixteen, any seventeen, any eighteen, any nineteen, any twenty, any twenty-one, any twenty-two, any twenty-three, any twenty-four, any twenty-five, any twenty-six, any twenty-seven, any twenty-eight, any twenty-nine, any thirty, any thirty-one, any thirty-two, any thirty-three, any thirty-four, any thirty-five, any thirty-six, any thirty-seven, any thirty-eight, any thirty-nine, any forty, any forty-one, any forty-two, any forty-three, any forty-four, any forty-five, any forty-six, any forty-seven, any forty-eight, any forty-nine, any fifty, any fifty-one, any fifty-two, any fifty-three, any fifty-four, any fifty-five, any fifty-six, any fifty-seven, any fifty-eight, any fifty-nine, any sixty, any sixty-one, any sixty-two, any sixty-three, any sixty-four, any sixty-five, any sixty-six, any sixty-seven, any sixty-eight, any sixty-nine, any seventy, any seventy-one, any seventy-two, any seventy-three, any seventy-four, any seventy-five, any seventy-six, any seventy-seven, any seventy-eight, any seventy-nine, any eighty, any eighty-one, any eighty-two, any eighty-three, any eighty-four, any eighty-five, any eighty-six, any eighty-seven, any eighty-eight, any eighty-nine, any ninety, any ninety-one, any ninety-two, any ninety-three, any ninety-four, any ninety-five, any ninety-six, any ninety-seven, any ninety-eight, any ninety-nine, any one hundred, any one hundred and one, any one hundred and two, any one hundred and three, any one hundred and four, any one hundred and five, any one hundred and six, any one hundred and seven, any one hundred and eight, any one hundred and nine, any one hundred ten, any one hundred eleven, any one hundred twelve, any one hundred thirteen, any one hundred fourteen, any one hundred fifteen, any one hundred sixteen, any one hundred seventeen, any one hundred eighteen, any one hundred nineteen, any one hundred twenty, any one hundred twenty-one, or any one hundred twenty-two of the molecules recited in a list described herein. A plurality may include a least any of the numbers recited above. A plurality may include more than any of the numbers recited above. A plurality may include a range of any of those recited above. In some embodiments, a C-RNA signature indicative of preeclampsia includes just one of the biomarkers recited above.

The identification and/or quantification of one of these C-RNA signatures within a sample obtained from a subject can be used to determine that the subject suffers from preeclampsia or is at a risk of developing preeclampsia.

A sample may be a biological sample or biosample, including but not limited to blood, serum, plasma, sweat, tears, urine, sputum, lymph, saliva, amniotic fluid, a tissue biopsy, swab, or smear, including for example, but not limited to, a placental tissue sample. In some preferred embodiments, a biological sample is a cell free plasma sample. A biological sample may be a maternal sample obtained from a pregnant female subject.

As used herein, the term “subject” refers to a human subject as well as a non-human mammalian subject. Although the examples herein concern humans and the language is primarily directed to human concerns, the concept of this disclosure is applicable to any mammal, and is useful in the fields of veterinary medicine, animal sciences, research laboratories and such.

A subject may be a pregnant female, including a pregnant female in any gestational stages of pregnancy. The gestational stage of pregnancy may be, for example, the first trimester, the second trimester, including late second trimester, or the third trimester, including early third trimester. The gestational stage of pregnancy may be, for example, before 16 weeks of pregnancy, before 20 weeks of pregnancy, or after 20 weeks of pregnancy. The gestational stage of pregnancy may be, for example, 8-18 weeks of pregnancy, 10-14 weeks of pregnancy, 11-14 weeks of pregnancy, 11-13 weeks, or 12-13 weeks of pregnancy.

The discovery of cell-free fetal nucleic acids in maternal plasma has opened up new possibilities for noninvasive prenatal diagnosis. Over the last few years, a number of approaches have been demonstrated to allow such circulating fetal nucleic acids to be used for the prenatal detection of chromosomal aneuploidies. Any of the methods described for example in Poon et al., 2000, Clin Chem; 1832-4; Poon et al., 2001, Ann N Y Acad Sci; 945:207-10; Ng et al., 2003, Clin Chem; 49(5):727-31; Ng et al., 2003, Proc Natl Acad Sci USA;100(8):4748-53; Tsui et al., 2004, J Med Genet; 41(6):461-7; Go et al., 2004, Clin Chem; 50(8):1413-4; Smets et al., 2006, Clin Chim Acta; 364(1-2):22-32; Tsui et al., 2006, Methods Mol Biol; 336:123-34; Purwosunu et al., 2007, Clin Chem; 53(3):399-404; Chim et al., 2008, Clin Chem; 54(3):482-90; Tsui and Lo, 2008, Methods Mol Biol; 444:275-89; Lo, 2008, Ann N Y Acad Sci; 1137:140-143; Miura et al., 2010, Prenat Diagn; 30(9):849-61; Li et al., 2012, Clin Chim Acta; 413(5-6):568-76; Williams et al., 2013, Proc Natl Acad Sci USA; 110(11):4255-60; Tsui et al., 2014, Clin Chem; 60(7):954-62; Tsang et al., 2017, Proc Natl Acad Sci USA; 114(37):E7786-E7795, and US Patent Publication US 2014/0243212 may be used in the methods described herein.

The detection and identification of biomarkers of a C-RNA signature within the maternal circulation indicative of preeclampsia or a risk for developing preeclampsia may involve any of a variety of technologies. For example, biomarkers may be detected in serum by radioimmunoassay or the polymerase chain reaction (PCR) technique may be used.

In various embodiments, the identification of the biomarkers of a C-RNA signature within the maternal circulation indicative of preeclampsia or a risk for developing preeclampsia may involve sequencing the C-RNA molecules. Any of a number of sequencing technologies can be utilized, including, but not limited to, any of a variety of high-throughput sequencing techniques.

In some embodiments, the C-RNA population within a maternal biosample may be subject to enrichment of RNA sequences the include protein-coding sequences prior to sequencing. Any of a variety of platforms available for whole-exome enrichment and sequencing may be used, including but not limited to the Agilent SureSelect Human All Exon platform (Chen et al., 2015a, Cold Spring Harb Protoc; 2015(7):626-33. doi: 10.1101/pdb.prot083659); the Roche NimbleGen SeqCap EZ Exome Library SR platform (Chen et al., 2015b, Cold Spring Harb Protoc; 2015(7):634-41. doi: 10.1101/pdb.prot084855); or the Illumina TruSeq Exome Enrichment platform (Chen et al., 2015c, Cold Spring Harb Protoc; 2015(7):642-8. doi:10.1101/pdb.prot084863). See also “TruSeq™ Exome Enrichment Guide,” Catalog # FC-930-1012 Part #15013230 Rev. B November 2010 and Illumina's “TruSeq™ RNA Sample Preparation Guide,” Catalog #RS-122-9001DOC Part #15026495 Rev. F March 2014.

In particular embodiments, biomarkers of a C-RNA signature within the maternal circulation indicative of preeclampsia or a risk for developing preeclampsia may be detected and identified using microarray techniques. In this method, polynucleotide sequences of interest are plated, or arrayed, on a microchip substrate. The arrayed sequences are then hybridized with a maternal biosample, or a purified and/or enriched portion thereof. Microarrays may include a variety of solid supports including, but not limited to, beads, glass microscope slides, glass wafers, gold, silicon, microchips, and other plastic, metal, ceramic, or biological surfaces. Microarray analysis can be performed by commercially available equipment, following manufacturer's protocols, such as by using Illumina's technology.

With obtaining, shipping, storing, and/or processing blood samples for the preparation of circulating RNA, steps may be taken to stabilize the sample and/or prevent the disruption of cell membranes resulting in the release of cellular RNAs into the sample. For example, in some embodiments, blood samples may be collected, shipped, and/or stored in tubes that have cell- and DNA-stabilizing properties, such as Streck Cell-Free DNA BCT® blood collection tubes, prior to processing into plasma. In some embodiments, blood samples are not exposed to EDTA. See, for example, Qin et al., 2013, BMC Research Notes; 6:380 and Medina Diaz et al., 2016, PLoS ONE; 11(11):e0166354.

In some embodiments, blood samples are processed into plasma within about 24 to about 72 hours of the blood draw, and in some embodiments, within about 24 hours of the blood draw. In some embodiments, blood samples are maintained, stored, and/or shipped at room temperature prior to processing into plasma.

In some embodiments, blood samples are maintained, stored, and/or shipped without exposure to chilling (for example, on ice) or freezing prior to processing into plasma.

The disclosure includes kits for use in the diagnosis of preeclampsia and the identification of pregnant women at risk for developing preeclampsia. A kit is any manufacture (e.g. a package or container) including at least one reagent, e.g. a probe, for specifically detecting a C-RNA signature within the maternal circulation as described herein that is indicative of preeclampsia or a risk for developing preeclampsia. The kit may be promoted, distributed, or sold as a unit for performing the methods of the present disclosure.

The use of signatures of circulating RNA found in the maternal circulation specific to preeclampsia in noninvasive methods for the diagnosis of preeclampsia and the identification of pregnant women at risk for developing preeclampsia may be combined with appropriate monitoring and medical management. For example, further tests may be ordered. Such test may include, for example, blood tests to measure liver function, kidney function, and/or platelet and various clotting proteins, urine analysis to measure protein or creatinine levels, fetal ultrasound to measure monitor fetal growth, weight, and amniotic fluid, a nonstress test to measure how fetal heart rate with fetal movement, and/or a biophysical profile using ultrasound to measure your fetal breathing, muscle tone, and movement and the volume of amniotic fluid may be ordered. Therapeutic interventions may include, for example, increasing the frequency of prenatal visits, antihypertensive medications to lower blood pressure, corticosteroid medications, anticonvulsant medications, bed rest, hospitalization, and/or early delivery. See, for example, Townsend et al., 2016 “Current best practice in the management of hypertensive disorders in pregnancy,” Integr Blood Press Control; 9: 79-94.

Therapeutic interventions may include the administration of low dose aspirin to pregnant women identified at risk of for developing preeclampsia. A recent multicenter, double-blind, placebo-controlled trial demonstrated that treatment of women at high risk for preterm preeclampsia with low-dose aspirin resulted in a lower incidence of this diagnosis compared to placebo (Rolnik et al., 2017, “Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia,” N Engl J Med; 377(7):613-622). Dosages of low dose aspirin include, but are not limited to, about 50 to about 150 mg per day, about 60 to about 80 mg per day, about 100 or more mg per day, or about 150 mg per day. Administration may begin, for example, at or before 16 weeks of gestation or from 11 to 14 weeks of gestation. Administration may continue thru 36 weeks of gestation.

The invention is defined in the claims. However, below is provided a non-exhaustive list of non-limiting embodiments. Any one or more of the features of these embodiments may be combined with any one or more features of another example, embodiment, or aspect described herein.

Embodiment 1 includes a method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method comprising:

identifying in a biosample obtained from the pregnant women a plurality of circulating RNA (C-RNA) molecules;

wherein a plurality of C-RNA molecules selected from:

a plurality of C-RNA molecules encoding at least a portion of a protein selected from any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or

a plurality of C-RNA molecules encoding at least a portion of a protein selected from any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768

is indicative of preeclampsia and/or an increased risk for preeclampsia in the pregnant women.

Embodiment 2 includes a method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method comprising:

obtaining a biosample from the pregnant female;

purifying a population of circulating RNA (C-RNA) molecules from the biosample;

identifying protein coding sequences encoded by the C-RNA molecules within the purified population of C-RNA molecules;

wherein the protein coding sequences encoded by the C-RNA molecules encoding at least a portion of a protein are selected from:

any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or

any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or an increased risk for preeclampsia in the pregnant women.

Embodiment 3 includes a method of Embodiment 1 or 2, wherein identifying protein coding sequences encoded by C-RNA molecules within the biosample comprises hybridization, reverse transcriptase PCR, microarray chip analysis, or sequencing.

Embodiment 4 includes the method of Embodiment 1 or 2, wherein identifying protein coding sequences encoded by the C-RNA molecules within the biosample comprises sequencing.

Embodiment 4 includes the method of Embodiment 4, wherein sequencing comprises massively parallel sequencing of clonally amplified molecules.

Embodiment 6 includes the method of Embodiment 4 or 5, wherein sequencing comprises RNA sequencing.

Embodiment 7 includes the method of any one of Embodiments 1 to 6, further comprising:

removing intact cells from the biosample;

treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA);

synthesizing complementary DNA (cDNA) from C-RNA molecules in the biosample; and/or

enriching the cDNA sequences for DNA sequences that encode proteins by exome enrichment;

prior to identifying protein coding sequence encoded by the circulating RNA (C-RNA) molecules.

Embodiment 8 includes a method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method comprising:

obtaining a biological sample from the pregnant female;

removing intact cells from the biosample;

treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA);

synthesizing complementary DNA (cDNA) from RNA molecules in the biosample;

enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment);

sequencing the resulting enriched cDNA sequences; and

identifying protein coding sequences encoded by enriched C-RNA molecules;

wherein protein coding sequences encoded by the C-RNA molecules encoding at least a portion of a protein selected from:

any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or

any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or an increased risk for preeclampsia in the pregnant women.

Embodiment 9 includes a method comprising:

obtaining a biological sample from the pregnant female;

removing intact cells from the biosample;

treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA);

synthesizing complementary DNA (cDNA) from RNA molecules in the biosample;

enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment);

sequencing the resulting enriched cDNA sequences; and

identifying protein coding sequences encoded by the enriched C-RNA molecules;

wherein the protein coding sequences encoded by the C-RNA molecules includes at least a portion of a protein are selected from:

any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or

any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768.

Embodiment 10 includes the method of any one of Embodiments 1 to 9, wherein the biosample comprises plasma.

Embodiments 11 includes the method of any one of Embodiments 1 to 10, wherein the biosample is obtained from a pregnant female at less than 16 weeks gestation or at less than 20 weeks gestation.

Embodiment 12 includes the method of any one of Embodiments 1 to 10, wherein the biosample is obtained from a pregnant female at greater than 20 weeks gestation.

Embodiment 13 includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature comprising any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7.

Embodiment 14 includes a circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature comprising any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768.

Embodiment 15 includes a solid support array comprising a plurality of agents capable of binding and/or identifying a C-RNA signature of Embodiment 13 or 14.

Embodiment 16 includes a kit comprising a plurality of probes capable of binding and/or identifying a C-RNA signature of Embodiment 13 or 14.

Embodiment 17 includes a kit comprising a plurality of primers for selectively amplifying a C-RNA signature of Embodiment 13 or 14.

Embodiment 18 includes the method of any one of Embodiments 1 to 12, wherein sample is a blood sample and the blood samples is collected, shipped, and/or stored in a tube that has cell- and DNA-stabilizing properties prior to processing the blood sample into plasma.

Embodiment 19 includes the method of Embodiment 18, wherein the tube comprises a Streck Cell-Free DNA BCT® blood collection tube.

The present invention is illustrated by the following examples. It is to be understood that the particular examples, materials, amounts, and procedures are to be interpreted broadly in accordance with the scope and spirit of the invention as set forth herein.

EXAMPLES Example 1 C-RNA Signatures Unique to Pregnancy

The presence of circulating nucleic acid in maternal plasma provides a window into the progression and health of the fetus and the placenta (FIG. 1). Circulating RNA (C-RNA) is detected in maternal circulation and originates from two predominant sources. A significant fraction of C-RNA originates from apoptotic cells, which release vesicles containing C-RNA into the blood stream. C-RNA also enters maternal circulation through the shedding of active signaling vesicles such as exosomes and microvesicles from a variety of cell types. As shown in FIG. 2, C-RNA is therefore comprised of the byproducts of cell death as well as active signaling products. Characteristics of C-RNA include generation through common processes, release from cells throughout the body, and stable and contained in vesicles. It represents a circulating transcriptome that reflects tissue-specific changes in gene expression, signaling, and cell death.

C-RNA has the potential to be an excellent biomarker for at least the following reasons:

1) All C-RNA is contained within membrane bound vesicles, which protects the C-RNA from degradation, making it quite stable in the blood. 2) C-RNA originates from all cell types. For example, C-RNA has been shown to contain transcripts from both the placenta and the developing fetus. The diverse origins of C-RNA give it the potential to be a rich repository for accessing information on both fetal and overall maternal health.

C-RNA libraries were prepared from plasma samples using standard Illumina library prep and whole exome enrichment technology. This is shown in FIG. 3. Specifically, Illumina TruSeq™ library prep and RNA Access Enrichment were used. Using this approach, libraries were generated that have 90% of the reads aligning to the human coding region (FIG. 3 and FIG. 7). Samples were downsampled to 50 M reads and ≥40 M mapped reads were used for downstream analysis. Samples were processed using the C-RNA workflow shown in FIG. 3. Dual Indexed libraries. Sequenced 50X50 on Hiseq2000

As shown in FIG. 4, comparing results from plasma samples from third trimester pregnant women to plasma samples from non-pregnant women provides a clear signature unique to pregnancy. The top twenty differential abundance genes of this signature are CSHL1, CSH2, KISS1, CGA, PLAC4, PSG1, GH2, PSG3, PSG4, PSG7, PSG11, CSH1, PSG2, HSD3B1, GRHL2, LGALS14, FCGR1C, PSG5, LGALS13, and GCM1. The majority of the genes identified in the pregnancy signature are placentally expressed and also correlate with published data. These results also confirm that placental RNA can be accessed in in the maternal circulation.

Example 2 C-RNA Signatures Across Gestational Age

This example characterized C-RNA signatures across different gestational ages throughout pregnancy. It is expected that the changes in C-RNA signatures at different time points longitudinally across pregnancy will be more subtle than the differences between C-RNA signatures of pregnant and non-pregnant samples noted in Example 1. As shown in FIG. 5, clear temporal changes in C-RNA profiles of the signature genes were observed as pregnancy progressed, with a clear group of genes upregulated in the first trimester and clear group of genes that increase in the third trimester.

These genes included CGB8, CGB5, ZSCAN23, HSPA1A, PMAIP1, C8orf4, ITM2B, IFIT2, CD74, HSPA6, TFAP2A, TRPV6, EXPH5, CAPN6, ALDH3B2, RAB3B, MUC15, GSTA3, GRHL2, and CSHL1, as listed in FIG. 5.

These genes may also include CSHL1, CSH2, KISS1, CGA, PLAC4, PSG1, GH2, PSG3, PSG4, PSG7, PSG11, CSH1, PSG2, HSD3B1, GRHL2, LGALS14, FCGR1C, PSG5, LGALS13, and GCM1.

These changes throughout the course of pregnancy correlate with published data from both Steve Quake and Dennis Lo. See, for example, Maron et al., 2007, “Gene expression analysis in pregnant women and their infants identifies unique fetal biomarkers that circulate in maternal blood,” J Clin Invest; 117(10):3007-3019; Koh et al., 2014, “Noninvasive in vivo monitoring of tissue-specific global gene expression in humans,” Proc Natl Acad Sci USA; 111(20):7361-6; and Ngo et al., 2018, “Noninvasive blood tests for fetal development predict gestational age and preterm delivery,” Science; 360(6393):1133-1136. C-RNA signatures correlating with patterns of gene expression of the placenta were found. Thus, this approach is able to detect subtle changes within pregnancy and provides non-invasive means to monitor placental health.

Example 3 C-RNA Signatures of Preeclampsia

With this example, C-RNA signatures unique to preeclampsia were identified. C-RNA signatures were determined in samples collected from pregnant women diagnosed with preeclampsia from two studies, the RGH14 Study (registered with clinical trials.gov as NCT0208494) and the Pearl Study (also referred to herein as the Pearl Biobank; registered with clinical trials.gov as NCT02379832)), were assayed (FIG. 6). Two tubes of blood were collected at the time of diagnosis for preeclampsia. Eighty controls samples matched for gestational age were collected to minimize transcriptional variability not related to the preeclampsia disease state and to control for gestational age differences in C-RNA signatures. Samples from the RGH14 study were used to identify a set of biologically relevant genes, and the predictive value of these biomarkers was validated in an independent cohort of samples from the Pearl Biobank.

In the analysis of the RGH14 data, C-RNA signatures unique to preeclampsia (PE) were identified using four different methods, the TREAT method, a Bootstrap method, a jackknifing method, and the Adaboost method. Example 3 focuses on the first 3 analysis methods and Example four focuses on the Adaboost method.

The t-test relative to threshold (TREAT) statistical method utilizing the EDGR program allows researchers to formally test (with associated p-values) whether the differential expression in a microarray experiment is greater than a given (biologically meaningful) threshold. See McCarthy and Smyth, 2009 “Testing significance relative to a fold-change threshold is a TREAT,” Bioinformatics; 25(6):765-71 for a more detailed description of the TREAT statistical method and Robinson et al., 2010, “edgeR: a Bioconductor package for differential expression analysis of digital gene expression data,” Bioinformatics; 26:139-140 for a more detailed description of the EDGR program. See Freund and Schapire, 1997, “A Decision-Theoretic Generalization of On-Line Learning and an Application to Boosting,” Journal of Computer and Systems Sciences; 55(1):119-139 and Pedregosa et al., 2011, “Scikit-learn: Machine Learning in Python,” JMLR; 12:2825-2830 for a more detailed description of the Adaboost method. The Adaboost method will be discussed in Example 4.

In the first method, standard statistical testing (TREAT method) was used to identify genes that are statistically different in the RGH14 preeclampsia cohort of 40 patients as compared to a subset of matched controls (40 patients). 122 genes were identified as statistically different in the preeclampsia cohort (40 patients) as compared to a subset of matched controls (40 patients) (FIG. 8, right panel). These genes include CYP26B1, IRF6, MYH14, PODXL, PPP1R3C, SH3RF2, TMC7, ZNF366, ADCY1, C6, FAM219A, HAO2, IGIP, IL1R2, NTRK2, SH3PXD2A, SSUH2, SULT2A1, FMO3, FSTL3, GATA5, HTRA1, C8B, H19, MN1, NFE2L1, PRDM16, AP3B2, EMP1, FLNC, STAG3, CPB2, TENC1, RP1L1, A1CF, NPR1, TEK, ERRFI1, ARHGEF15, CD34, RSPO3, ALPK3, SAMD4A, ZCCHC24, LEAP2, MYL2, NRG3, ZBTB16, SERPINA3, AQP7, SRPX, UACA, ANO1, FKBPS, SCN5A, PTPN21, CACNA1C, ERG, SOX17, WWTR1, AIF1L, CA3, HRG, TAT, AQP7P1, ADRA2C, SYNPO, FN1, GPR116, KRT17, AZGP1, BCL6B, KIF1C, CLIC5, GPR4, GJA5, OLAH, C14orf37, ZEB1, JAG2, KIF26A, APOLD1, PNMT, MYOM3, PITPNM3, TIMP4, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, VSIG4, HBG2, CADM2, LAMPS, PTGDR2, NOMO1, NXF3, PLD4, BPIFB3, PACSIN1, CUX2, FLG, CLEC4C, and KRT5.

The TREAT method did not identify a set of genes that 100% accurately classifies the preeclampsia patients into a separate group (FIG. 15). However, focusing in on these identified genes did improve classification compared to using the entire data set of all measured genes (FIG. 8, left panel). This highlights the value of focusing in on a subset of genes for prediction. However, with the TREAT method, a significant amount of variability was observed in the genes identified depending on which controls were selected. To deal with this biological variability and further improve the predictive value of our gene list, a second bootstrapping approach was developed.

In the RGH14 study more control samples (80) are available than preeclampsia patient samples (40). Thus, the RGH14 cohort of 40 preeclampsia patient samples was compared to a random selection of 40 controls samples (still matched for gestational age) and a gene list that is statistically different in the preeclampsia cohort was identified. As shown in FIG. 9, this was then repeated 1,000 times, to identify how often a set of genes was identified. A significant subset of genes only show up less than 10 times out of the 1,000 iterations (less than 1% of the 1,000 iterations). These low frequency genes most likely are due to biological noise and may not reflect a gene that is universally specific to preeclampsia. So, the gene list was further downselected by requiring a gene to be considered as statistically different in the preeclampsia cohort only if identified in 50% of the 1,000 iterations performed (FIG. 9, right panel). As shown in FIG. 10, differential transcript abundance with the additional bootstrapping selection distinguishes preeclampsia samples from healthy controls. Using this additional requirement helped address biological variability and further improved the ability to classify preeclampsia samples correctly.

Using this Bootstrap method, 27 genes were identified as statistically associated with preeclampsia. These genes include TIMP4, FLG, HTRA4, AMPH, LCN6, CRH, TEAD4, ARMS2, PAPPA2, SEMA3G, ADAMTS1, ALOX15B, SLC9A3R2, TIMP3, IGFBP5, HSPA12B, CLEC4C, KRT5, PRG2, PRX, ARHGEF25, ADAMTS2, DAAM2, FAM107A, LEP, NES, and VSIG4. The genes identified with this bootstrapping method had excellent concordance with published data. Approximately 75% of these genes are expressed by the placenta. As shown in FIG. 11, there is overlap with known markers of preeclampsia, including PAPPA and CRH. And, a significant number of these genes are involved in embryo development, extracellular matrix remodeling, immune regulation, and cardiovascular function, all pathways known to be dysregulated in preeclampsia.

A third jackknifing approach was also developed to capture the subset of genes with the highest predictive value. This approach is similar to the bootstrapping method. Patients from both preeclampsia and control groups were randomly subsampled and differentially abundant genes identified 1,000 times. Instead of using the frequency with which a gene is identified as statistically different, the jackknifing approach calculated confidence intervals (95%, one-sided) for the p-value of each transcript. Genes where this confidence interval exceeded 0.05 were excluded. (FIG. 16, left panel).

Using the jackknifing approach, 30 genes were identified as predictive of preeclampsia: VSIG4, ADAMTS2, NES, FAM107A, LEP, DAAM2, ARHGEF25, TIMP3, PRX, ALOX15B, HSPA12B, IGFBP5, CLEC4C, SLC9A3R2, ADAMTS1, SEMA3G, KRT5, AMPH, PRG2, PAPPA2, TEAD4, CRH, PITPNM3, TIMP4, PNMT, ZEB1, APOLD1, PLD4, CUX2, HTRA4.

As shown in FIG. 16 right panel, this approach gave good classification of preeclampsia patients in the RGH14 data set (compare FIG. 15 (TREAT), FIG. 10 (bootstrapping) and FIG. 16 (jackknifing)). Each identified gene list was also used to classify preeclampsia samples in the independent Pearl Biobank dataset. As shown in FIG. 17, each gene list was able to classify preeclampsia samples.

All genes identified by the bootstrapping and jackknifing methods are represented in the 122 TREAT method genes (Table 2, DEX analysis, TruSeq library prep method). The bootstrapping and jackknifing approach gene lists are highly concordant, with over 70% of genes in common. Nearly 90% of transcripts identified by any approach exhibit increased transcript abundance in preeclampsia patients, consistent with elevated signaling and/or cell death in this disease.

Example 4 Identification of C-RNA Signatures with Adaboost

With this example an alternative approach, a publicly available machine learning algorithm called adaboost, was used to identify a specific C-RNA signature associated with preeclampsia. As shown in FIG. 12, this approach identifies a set of genes that has the most predictive power to classify a sample as preeclampsia (PE) or normal. Using this gene list, the clearest separation of a preeclampsia cohort from healthy controls was observed. However, this approach can also be very susceptible to overtraining to the samples used to build the model. Thus, the predictive model was validated using a completely independent data set from the PEARL study (FIG. 13). Using this Adaboost gene list, 85% of the preeclampsia samples were accurately classify with 85% specificity (FIG. 14). Overall, the Adaboost machine learning approach built the most accurate predictive model for preeclampsia.

Using the Adaboost method, 75 genes were identified as statistically associated with preeclampsia (Table 3, AdaBoost Analysis, TruSeq library prep method). These genes include ARRDC2, JUN, SKIL, ATP13A3, PDE8B, GSTA3, PAPPA2, TIPARP, LEP, RGP1, USP54, CLEC4C, MRPS35, ARHGEF25, CUX2, HEATR9, FSTL3, DDI2, ZMYM6, ST6GALNAC3, GBP2, NES, ETV3, ADAM17, ATOH8, SLC4A3, TRAF3IP1, TTC21A, HEG1, ASTE1, TMEM108, ENC1, SCAMP1, ARRDC3, SLC26A2, SLIT3, CLIC5, TNFRSF21, PPP1R17, TPST1, GATSL2, SPDYE5, HIPK2, MTRNR2L6, CLCN1, GINS4, CRH, C10orf2, TRUB1, PRG2, ACY3, FAR2, CD63, CKAP4, TPCN1, RNF6, THTPA, FOS, PARN, ORAI3, ELMO3, SMPD3, SERPINF1, TMEM11, PSMD11, EBI3, CLEC4M, CCDC151, CPAMD8, CNFN, LILRA4, ADA, C22orf39, PI4KAP1, and ARFGAP3.

A refined AdaBoost model was also developed for robust classification of PE samples. In order to create a generalized machine learning model that could accurately predict new samples, we used a rigorous approach that avoided overfitting to a single dataset and validated the final classifier with samples not used for model building. As illustrated in FIG. 18, the RGH14 dataset was divided into 6 pieces by random selection: a holdout subset with 12% of samples which was excluded from model building, and 5 evenly sized test subsets. For each iteration subsets were designated as training data or test samples. This process, starting at building the AdaBoost model was repeated for a minimum of 10 times on this data subset. After 50 high performing models were built for the 5 test-train subsets, the estimators from all models were merged into a single AdaBoost model.

Using the refined AdaBoost model, 11 genes were identified as statically associated with preeclampsia. These genes include CLEC4C, ARHGEF25, ADAMTS2, LEP, ARRDC2, SKIL, PAPPA2, VSIG4, ARRDC4, CRH and NES. The performance of this predictive model was validated using the hold out data set from RGH14 as well as in the completely independent Pearl Biobank cohort (FIG. 19).

AdaBoost Model Creation Description. The AdaBoost classification approach was refined in order to obtain more specific gene sets (AdaBoost Refined 1-7) by the following approach, also illustrated in FIG. 18. The RGH14 dataset was divided into 6 pieces by random selection: a holdout subset with 12% of samples which was excluded from model building, and 5 evenly sized test subsets.

For each of the test subsets, training data was assigned as all samples in neither the holdout or test samples. Gene counts for the test and training samples were TMM-normalized in edgeR, then standardized such that the training data has mean of 0 and standard deviation of 1 for each gene. An AdaBoost model with 90 estimators and 1.6 learning rate was then fit to the training data. Feature pruning was then performed by determining the feature importance of each gene in the model and testing the impact of eliminating estimators using genes with importance below a threshold value. The threshold resulting in the best performance (as measured by Matthew's correlation coefficient on test data classification) with the fewest genes was selected, and that model retained. This process, starting at building the AdaBoost model was repeated for a minimum of 10 times on this data subset.

After all 50 plus models were built for the 5 test-train subsets, the estimators from all models were merged into a single AdaBoost model. Feature pruning was performed again, this time using the percent of models incorporating a gene to for threshold values and assessing performance with the average negative log loss value for the classification of each test subset. The model which obtained the maximal negative log loss value with the fewest genes was selected as the final AdaBoost model.

AdaBoost Gene Lists. Upon repetition of this process, slight variations were observed in the genes selected for the final model, due to innate randomization in the AdaBoost algorithm implementation, however performance remained high for predicting the test data, holdout data, and independent (Pearl) datasets.

Eleven total genes were observed in at least one of 14 AdaBoost Refined models generated: ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, NES, PAPPA2, SKIL, VSIG4 (AdaBoost Refined 1), although no models were generated that included all simultaneously.

Two observed gene sets offered the highest performance on classification of independent data. These are AdaBoost Refined 2: ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, VSIG4 and AdaBoost Refined 3: ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, PAPPA2, SKIL, VSIG4.

Four additional gene sets performed almost as highly as AdaBoost Refined 2-3. These are AdaBoost Refined 4: ADAMTS2, ARHGEF25, ARRDC4, CLEC4C, LEP, NES, SKIL, VSIG4; AdaBoost Refined 5: ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, CRH, LEP, PAPPA2, SKIL, VSIG4; AdaBoost Refined 6: ADAMTS2, ARHGEF25, ARRDC2, CLEC4C, LEP, SKIL; and AdaBoost Refined 7: ADAMTS2, ARHGEF25, ARRDC2, ARRDC4, CLEC4C, LEP, PAPPA2, SKIL.

Example 5 Identification of C-RNA Signature with Transposome Based Library Prep

The RGH14 samples were also processed through the Illumina Nextera Flex for Enrichment protocol, enriched for whole exome and sequenced to >40 million reads. This approach is more sensitive and robust for low inputs, thus likely to identify additional genes predictive of preeclampsia. This dataset was run through three analysis methods, standard differential expression analysis (TREAT), jackknifing, and the refined Adaboost model. See Example 3 and Example 4 for detailed description of these analysis methods.

Changing the method for generating libraries altered the genes detected in all three analysis methods. For the TREAT method, 26 genes were identified as differentially abundant in preeclampsia, with the majority again showing elevated abundance in preeclampsia (See Table 2, DEX Analysis, Nextera Flex for Enrichment library prep method). These genes include ADAMTS1, ADAMTS2, ALOX15B, AMPH, ARHGEF25, CELF4, DAAM2, FAM107A, HSPA12B, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PACSIN1, PAPPA2, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, VSIG4. FIG. 20 shows classification of the RGH14 samples with this gene list.

Applying the jackknifing analysis method downselected the TREAT list to 22 genes identified as differentially abundant in preeclampsia. These genes included ADAMTS1, ADAMTS2, ALOX15B, ARHGEF25, CELF4, DAAM2, FAM107A, HTRA4, IGFBP5, KCNA5, KRT5, LCN6, LEP, LRRC26, NES, OLAH, PRX, PTGDR2, SEMA3G, SLC9A3R2, TIMP3, VSIG4. The improved performance of this list is shown in FIG. 20.

The refined AdaBoost model approach was applied to this data, as described in Example 4. Using this method, 24 genes are identified as statically associated with preeclampsia (Table 3, AdaBoost Analysis, Nextera Flex for Enrichment library prep method). These genes include LEP, PAPPA2, KCNA5, ADAMTS2, MYOM3, ATP13A3, ARHGEF25, ADA, HTRA4, NES, CRH, ACY3, PLD4, SCT, NOX4, PACSIN1, SERPINF1, SKIL, SEMAG3, TIPARP, LRRC26, PHEX, LILRA4, and PER1. The performance of this predictive model is indicated in FIG. 21.

Example 6 Circulating Transcriptome Measurements from Maternal Blood Detects Early-Onset Preeclampsia Signature

Molecular tools to non-invasively monitor pregnancy health from conception to birth would enable accurate detection of pregnancies at risk for adverse outcomes. Circulating RNA (C-RNA) is released by all tissues into the bloodstream, offering an accessible, comprehensive measurement of placental, fetal and maternal health (Koh et al., 2014, Proceedings of the National Academy of Sciences; 111:7361-7366; and Tsui et al., 2014, Clinical Chemistry; 60:954-962). Preeclampsia (PE), a prevalent and potentially fatal pregnancy complication, is placental in origin but gains a substantial maternal component as the disease progresses (Staff et al., 2013, Hypertension; 61:932-942; and Chaiworapongsa et al., 2014, Nature Reviews Nephrology; 10, 466-480). Yet purported biomarkers have shown limited clinical utility (Poon and Nicolaides, 2014, Obstetrics and Gynecology International; 2014:1-11; Zeisler et al., 2016, N Engl J Med; 374:13-22; and Duhig et al., 2018, F1000Research; 7:242). Hypothesizing that characterization of the circulating transcriptome may identify better biomarkers, C-RNA was analyzed from 113 pregnancies, 40 at the time of early-onset PE diagnosis. Using a novel workflow, differences were identified in the abundance of 30 transcripts which are consistent with the biology of PE and represent placental, fetal, and maternal contributions. Further, a machine learning model was developed, demonstrating that only seven C-RNA transcripts are required to classify PE in two independents cohorts (92-98% accuracy). The global measurements of C-RNA disclosed in this example highlight the utility in monitoring both maternal and fetal health and hold great promise for the diagnosis and prediction of at-risk pregnancies.

Several studies have begun to investigate and identify potential biomarkers in C-RNA for a range of pregnancy complications (Pan et al., 2017, Clinical Chemistry; 63:1695-1704; Whitehead et al., 2016, Prenatal Diagnosis; 36:997-1008; Tsang et al., 2017, Proc Natl Acad Sci USA; 114: E7786-E7795; and Ngo et al., 2018, Science; 360:1133-1136). However, these studies have involved few patients and have been limited to monitoring small numbers of genes—almost exclusively placental and fetal derived transcripts. Measurements of the entire circulating transcriptome are difficult to perform because they require specific upfront sample collection and processing to minimize variability and contamination from cell lysis (Chiu et al., 2001, Clinical Chemistry; 47:1607-1613; and Page et al., 2013, PLoS ONE; 8: e77963). This complex workflow makes large clinical sample collections difficult to achieve because the labor required for immediate processing of blood samples is infeasible for many clinics (Marton and Weiner, 2013, BioMed Research International; 2013:891391). Therefore, with this example, a method was established that allows overnight shipment of blood to a processing lab where every step of sample preparation is performed in a controlled environment, providing a scalable platform for clinical trial level assessments (FIG. 22A).

The lynchpin of this method is the ability to ship blood overnight to a processing lab. The C-RNA pregnancy signal was assessed after overnight, room-temperature shipping in several tube types (FIGS. 26A-26C). Blood stored in EDTA tubes, the gold standard used by prior C-RNA studies, exhibited a reduction in the abundance of pregnancy-associated transcripts and overall instability of the transcriptomic profile (Qin et al., 2013, BMC Research Notes; 6:380). In contrast, the predominant tube type used for Non-Invasive Prenatal Testing (NIPT), Cell-Free DNA BCT (Streck), retained the signal from placental transcripts and had improved technical reproducibility (FIG. 26B) (Medina Diaz et al., 2016, PLoS ONE; 11:e0166354).

Shipment of blood allowed us to easily obtain an average of 5 mL plasma per patient from a single tube of blood. The difference in C-RNA data quality was assessed when using varying plasma volumes and determined that using <2 mL plasma significantly increased noise and decreased library complexity (FIGS. 27A and 27B). Thus 4 mL of plasma was used for the studies of this example to maximize confidence in data quality.

This novel workflow was validated by recapitulating previous work monitoring C-RNA dynamics of >10,000 transcripts per healthy pregnancy from first to third trimester. Using 152 samples collected serially from 45 healthy pregnancies (Pre-Eclampsia and Growth Restriction Longitudinal Study Control Cohort—PEARL; NCT02379832; Table 5), 156 significantly altered transcripts were identified, with the majority increasing in abundance as pregnancy progresses (FIG. 22B). 42% of the altered genes were identified in prior C-RNA studies (FIG. 22C) (Koh et al., 2014, Proceedings of the National Academy of Sciences; 111:7361-7366; and Tsui et al., 2014, Clinical Chemistry; 60:954-962). Of the 91 transcripts identified only in this study, 64% are expressed by placental and/or fetal tissues (FIGS. 22D and 28A-28C). Presumably, the remaining genes reflect the maternal response to pregnancy.

Study Design

For the next phase of investigation, the workflow was applied on clinical samples to measure C-RNA changes in PE (iPC, Illumina Preeclampsia Cohort). PE is a heterogeneous disorder and associated with different severity and patient outcomes based on whether it manifests before (early-onset) or after (late-onset) 34 gestational weeks (Staff et al., 2013, Hypertension; 61:932-942; Chaiworapongsa et al., 2014, Nature Reviews Nephrology; 10, 466-4803; and Dadelszen et al., 2003, Hypertension in Pregnancy; 22:143-148). This study to focused on the more severe early-onset form of PE and defined strict diagnostic criteria with clear inclusion and exclusion requirements—most critically excluding any individuals with a history of chronic hypertension—in order to obtain a clean cohort (Table 6) (Nakanishi et al., 2017, Pregnancy Hypertension; 7:39-43; and Hiltunen et al., 2017, PLoS ONE; 12:e0187729). Maternal characteristics, pregnancy outcomes, and medications in use were recorded throughout the study (Table 7). 113 samples were collected across 8 sites (Table 8), 40 at the time of PE diagnosis, and 73 controls gestationally-age matched within 1 week (FIG. 23A). All but one woman with PE gave birth prematurely, in contrast to 9.5% of controls, confirming these diagnostic criteria as identifying individuals severely impacted by this disease (FIG. 23C).

All samples were randomly distributed across multiple processing batches, then sequenced to ≥40 M reads. Standard differential expression analysis using the full cohort identified 42 altered transcripts, with 37 increased in PE (FIG. 24A, blue and orange). However, of concern was the high variability observed in the genes detected as altered when different subsets of controls were selected for analysis.

To address this discrepancy, a jackknifing approach was incorporated which allowed the identification of the genes that are most consistently altered (FIGS. 24A and 24B, orange). 1,000 iterations of differential analysis with randomly selected sample subsets were performed, which allowed the construction of confidence intervals for the p-values associated with each putatively altered transcript (FIG. 29A). 12 genes whose confidence interval exceeded 0.05 were excluded (FIG. 24B). These genes would not have been excluded by simply setting a threshold for baseline abundance or biological variance (FIG. 29B), however it was observed that these transcripts have lower predictive value (FIG. 29C). Hierarchical clustering indicates these genes are not altered universally in the PE cohort, and thus lack sensitivity (73%) for accurate classification of this condition (FIG. 29D).

The analysis then focused on the refined 30 gene set, 60% of which have previously been associated with PE (Namli et al., 2018, Hypertension in Pregnancy; 37: 9-17; Than et al., 2018, Frontiers in Immunology; 9:1661; Kramer et al., 2016, Placenta; 37:19-25; Winn et al., 2008, Endocrinology; 150:452-462; and Liu et al., 2018, Molecular Medicine Reports; 18:2937-2944). qPCR analysis confirmed 19 of 20 genes as significantly altered in PE (FIG. 24C, Table 9). Strikingly, 40% of these genes encode for extracellular or secreted protein products. Additionally, nearly all genes are involved in PE relevant processes, including extracellular matrix (ECM) remodeling, pregnancy duration, placental/fetal development, angiogenesis, and hypoxia response (Table 10). 67% of these transcripts were expressed by the placenta and/or fetus (FIG. 24D). In the remaining maternally expressed transcripts, cardiovascular and immune functions were well represented (Table 10). Hierarchical clustering of these genes effectively segregated PE and control samples with 98% sensitivity and 97% specificity (FIG. 24E). Intriguingly, clinical data for the two misidentified controls indicated potentially confounding health problems, as suggested by their use of hypertensive medication (Table 7).

Using the genes identified in iPC, the ability to cluster a cohort of samples obtained from an independent biobank was assessed—the Pre-Eclampsia and Growth Restriction Longitudinal Study (PEARL; NCT02379832; FIGS. 23B and 23C, Table 11). This cohort consisted of both early-(diagnosed at <34 weeks); and late-onset PE with gestationally age-matched controls. Early-onset PE samples clustered separately from matched controls with 83% sensitivity and 92% specificity, further validating the relevance of these transcripts (FIG. 24F). In contrast, no clustering was observed for the late-onset PE and matched control samples (FIG. 24G).

The iPC data was then used to build an AdaBoost model for robust classification of PE samples. In order to create a generalized machine learning model that could accurately predict new samples, a rigorous approach was used that avoided overfitting to a single dataset and validated the final classifier with samples not used for model building (FIGS. 30A-30D and FIGS. 31A-31E). Surprisingly, the final model only utilized 7 genes, 3 of which have not been previously reported (FIG. 25A). For the entire iPC cohort, this model classified samples with extremely high accuracy (AUC=0.99, sensitivity=98%, specificity=99%; FIGS. 25B and 25C, blue). Early-onset PE PEARL samples were also accurately classified (AUC=0.88, sensitivity=100%, specificity=83%; FIGS. 25B and 25C, pink). Unexpectedly, late-onset PE PEARL samples were also classified with reasonable accuracy (AUC=0.74, sensitivity=75%, specificity=67%; FIGS. 25B and 25C, green).

This gene set was highly concordant with transcripts identified by differential abundance analysis (FIG. 25D; Table 10). The classifier relied on both placentally and maternally expressed transcripts (FIG. 25E). All genes used by the model form protein products that are either extracellular or membrane bound. Despite the small number of genes selected by AdaBoost, a diversity of PE-relevant functions was observed, specifically cardiovascular function and angiogenesis, immune regulation, fetal development, and ECM remodeling.

Methods

Prospective Clinical Sample Collection. Pregnant patients were recruited in an Illumina sponsored clinical study protocol in compliance with the International Conference on Harmonization for Good Clinical Practice. Following informed consent, 20 mL whole blood samples were collected from 40 pregnant women with a diagnosis of preeclampsia before 34 weeks gestation with severe features defined per ACOG guidelines (Table 6). Samples from 76 healthy pregnancies were also collected and were matched for gestational age to the preeclampsia group. Three control samples developed term preeclampsia after blood collection and were excluded from data analysis. For detailed inclusion and exclusion criteria, see Table 6. Patient clinical history, treatment and birth outcome information were also recorded (Table 7).

Patients were recruited across 8 different clinical sites, including University of Texas Medical Branch (Galveston, Tex.), Tufts Medical Center (Boston, Mass.), Columbia University Irving Medical Center (New York, N.Y.), Winthrop University Hospital (Mineola, N.Y.), St. Peter's University Hospital (New Brunswick, N.J.), Christiana Care (Newark, Del.), Rutgers University Robert Wood Johnson Medical School (New Brunswick, N.J.) and New York Presbyterian/Queens (New York, N.Y.). The clinical protocol and informed consent were approved by each clinical site's Institutional Review Board. See Table 8 for patient distribution across clinical sites.

PEARL Validation Cohort Study Design. Illumina obtained plasma samples from the Preeclampsia and Growth Restriction Longitudinal study (PEARL; NCT02379832) to be used as an independent validation cohort. Plasma samples were obtained after the study had reached completion. PEARL samples were collected at the Centre hospitalier universitaire de Québec (CHU de Québec) with principal investigator Emmanual Buj old, MD, MSc. A group of 45 control pregnancies and 45 case pregnancies were recruited in this study and written informed consent was obtained for all patients. Only participants above 18 years of age were eligible, and all pregnancies were singleton.

Preeclampsia Group. The criteria for preeclampsia was defined based on the Society of Obstetricians and Gynecologists of Canada (SOGC) June 2014 criteria for preeclampsia, with a gestational age requirement between 20 and 41 weeks. A blood sample was taken once at the time of diagnosis.

Control Group. 45 pregnant women who were expected to have a normal pregnancy were recruited between 11 and 13 weeks gestational age. Each enrolled patient was followed longitudinally with blood drawn at 4 timepoints throughout pregnancy until birth. The control women were divided into three subgroups and subsequent follow up blood draws were staggered to cover the entire range of gestational ages throughout pregnancy (Table 5).

The PEARL control samples were used for two purposes. 153 longitudinal samples from 45 individual women were used to monitor placental dynamics throughout pregnancy. Additionally, control samples were selected for comparison to the preeclampsia cohort, which were matched for gestational age and used to validate the model.

Study Sample Processing. All samples from the Illumina prospective collection and the PEARL samples were processed identically by investigators blinded to disease status. Two tubes of blood were collected per patient in Cell-Free DNA BCT tubes (Streck) following the manufacturer instructions. Blood samples were stored and shipped at room temperature overnight and processed within 72 hours. Blood was centrifuged at 1,600×g for 20 minutes at room temperature, plasma transferred to a new tube and centrifuged additional 10 minutes at 16,000×g to remove residual cells. Plasma was stored at −80° C. until use. Circulating RNA was extracted from 4.5 mL of plasma using the Circulating Nucleic Acid Kit (Qiagen) followed by DNAse I digestion (Thermofisher) according to manufacturer's instructions.

cDNA Synthesis and Library Prep. Circulating RNA was fragmented at 94° C. for 8 minutes followed by random hexamer primed cDNA synthesis using the Illumina TruSight Tumor 170 Library Prep kit (Illumina). Illumina sequencing library prep was carried out according to TST170 Tumor Library Prep Kit for RNA, with the following modifications to accommodate low RNA inputs. All reactions were reduced to 25% of original volume and the ligation adaptor was used at 1 in 10 dilution. Library quality was assessed using High Sensitivity DNA Analysis kits on the Agilent Bioanalzyer 2100 (Agilent).

Whole Exome Enrichment. Sequencing libraries were quantified using Quant-iT PicoGreen dsDNA Kit (ThermoFisher Scientific), normalized to 200 ng input and pooled to 4 samples per enrichment reaction. Whole exome enrichment was carried out according to the TruSeq RNA Access Library Prep guide (Illumina). Additional blocking oligos lacking the 5′ biotin designed against hemoglobin genes HBA1, HBA2, and HBB were included in the enrichment reaction to reduce enrichment of these genes in the sequencing libraries. Final enrichment libraries were quantified using Quant-IT Picogreen dsDNA Kit (ThermoFisher Scientific), normalized and pooled for paired end 50 by 50 sequencing on Illumina HiSeq 2000 platforms to a minimum depth of 40 million reads per sample.

Data Analysis. Unless otherwise noted, all statistical testing was two-sided. Non-parametric testing was used when data were not normally distributed. Sequencing reads were mapped to human reference genome (hg19) with tophat (v2.0.13), and transcript abundance quantified with featureCounts (subread-1.4.6) against RefGene coordinates (obtained Oct. 27, 2014). Tissue expression data were obtained from Body Atlas (CorrelationEngine, BaseSpace, Illumina, Inc) (Kupershmidt, et al., 2010, PLoS ONE 5; 10.1371/journal.pone.0013066). vGenes with expression ≥2-fold higher than the median expression across all tissues in the placenta or any of the fetal tissues (brain, liver, lung, and thyroid) were assigned to that group. Subcellular localization was obtained from UniProt.

Differential expression analysis was performed in R (v3.4.2) with edgeR (v3.20.9), after exclusion of genes with a CPM ≤0.5 in <25% of samples. The dataset was normalized by the TMM method, and differentially abundant genes identified by the glmTreat test for a log fold change ≥1 followed by Bonferroni-Holm p-value correction. The same process was used for each jackknifing iteration, using 90% of samples in each group selected by random sampling without replacement. After 1,000 jackknifing iterations, the one-sided 95% confidence interval for gene-wise p-values was calculated with statsmodels (v0.8.0). Hierarchical clustering analysis was performed with squared Euclidean distance and average linkage.

AdaBoost was performed in python with scikit-learn (v0.19.1, sklearn.ensemble. AdaBoostClassifier). Optimal hyperparameter values (90 estimators, 1.6 learning rate) were determined by grid search, using Matthew's correlation coefficient to quantify performance. The overall AdaBoost model development strategy is illustrated in FIGS. 31A-31E. Datasets (TMM-normalized log CPM values of genes with a CPM ≤0.5 in <25% of samples) were standardized (sklearn.preprocessing. StandardScaler) prior to fitting classifiers. The same scaler fit on training data was applied to the corresponding testing dataset; all 5 scalers for the 5 training datasets were averaged for use with the final model. The decision function score was used to construct ROC curves and determine sample classification.

RT-qPCR validation assay and analysis. C-RNA was isolated and converted to cDNA from 2mls of plasma from 19 Preeclampsia (PE) and 19 matched control samples, which were selected randomly. The cDNA was pre-amplified using the TaqMan Preamp master Mix (cat: 4488593) for 16 cycles and diluted 10-fold to a final volume of 500 μL. For qPCR, the reaction mixture contained 54, of diluted pre-amplified cDNA, 104, of TaqMan gene expression master mix (cat: 4369542), 1 μL of TaqMan Probe, and 44, of water using the manufacturer's instructions. For each TaqMan probe (Table 9), three qPCR reactions were carried out per diluted cDNA sample and the Cq values were determined using Bio-Rad CFX manager software. To determine gene abundance for each target gene, the ΔΔCq=2{circumflex over ( )}−(target Cq−ref Cq_(avg)) was calculated using the mean Cq values between five reference gene probes (ref Cq_(avg)). To determine the fold change (PE/CTRL) for each probe, the ΔΔCq values for each sample was divided by the average ΔΔCq value for the matched control group.

Tube type study. To assess the effects of tube type and overnight shipping on circulating RNA quality, blood was drawn from pregnant and non-pregnant females in the following tube types: K2 EDTA (Beckton Dickinson), ACD (Beckton Dickinson), Cell Free RNA BCT tube (Streck), and 1 Cell Free DNA BCT tube (Streck). 8 mL of blood was drawn into each tube and shipped overnight either on ice packs (EDTA and ACD) or shipped at room temperature (Cell Free RNA and DNA BCT tubes). All shipped blood tubes were processed into plasma within 24 hours of the blood draw. As a reference, 8 mL of blood was also drawn into K2 EDTA tubes and processed within 4 hours into plasma on site and shipped as plasma on dry ice. All plasma processing and circulating RNA extraction was carried out as described in the methods section. 3 mL of plasma was used per condition to generate sequencing libraries for enrichment using Illumina protocols as described.

Reproducibility Study. Plasma was obtained from 10 individuals and split into 4 mL, 1 mL, and 0.5 mL volumes, with 3 replicates for each volume. Circulating RNA extraction (Qiagen Circulating Nucleic Acid Kit) and random primed cDNA synthesis were carried out on all samples as previously described. For libraries using 4.5 mL plasma inputs, sequencing libraries were generated using the TST170 Tumor Library Prep Kit as described above. For 1 mL and 0.5 mL inputs, the Accel-NGS 1S Plus DNA Library Kit (Swift Biosciences) was used to generate libraries. Whole exome enrichment and sequencing was carried out on all samples using as described above.

Discussion

This study focused on identifying differences that are universal to early-onset PE, supporting the ultimate goal of clinically actionable biomarker discovery. This required tailoring the analysis methods to account for the variability observed in the data. This variance stems from both the substantial biological noise in C-RNA measurements as well as the phenotypic diversity of PE. C-RNA is inherently more variable than single tissue transcriptomics because it represents a combination of cell death, signaling, and gene expression across all organs. Furthermore, PE exhibits a wide range of maternal and fetal outcomes which may be associated with different underlying molecular causes. While the genes that were eliminated may be biologically relevant in PE, they were not universal in the cohort. Interestingly, the excluded transcripts were elevated in specific women, who may represent a molecular subset of PE.

Larger cohorts will help elucidate if C-RNA can delineate PE subtypes, which is crucial to understanding the diverse pathophysiology of this condition.

The most universal set of transcripts was identified by AdaBoost. The success of this method was underscored by highly accurate classification of an independent early-onset PE cohort (PEARL). These samples were collected from a different population with significantly relaxed inclusion and exclusion criteria, for instance including women in the control group who had chronic hypertension, gestational diabetes, or Alport syndrome—none of which were misidentified as having PE. In contrast to hierarchical clustering, 17 of 24 individuals from the late-onset PE cohort were correctly classified by machine learning model of this example, surprising given the suggestion that early- and late-onset PE are distinct conditions. The findings of this example suggest there may be some pathways universally altered in all PE.

In every assessment, C-RNA revealed changes in placental, fetal, and maternally expressed transcripts. One of the most striking trends observed in PE samples was the increased abundance of myriad ECM remodeling and cell migration/invasion proteins (FAM107A, SLC9A3R2, TIMP4, ADAMTS1, PRG2, TIMP3, LEP, ADAMTS2, ZEB1, HSPA12B), tracking with dysfunctional extravillous trophoblast invasion and remodeling of maternal vessels characteristic in this disease. The maternal side of early-onset PE manifests as cardiovascular dysfunction, inflammation, and preterm birth (PNMT, ZEB1, CRH), all of which show molecular signs of aberrant behavior in the data of this example.

TABLE 5 PEARL Control Cohort Gestational Age Distribution for 45 healthy pregnancies Control Follow up Follow up Follow up Groups Recruitment visit #1 visit #2 visit #3 Group 1 (n = 15) 11^(0/7)-13^(6/7) weeks 14^(0/7)-17^(6/7) weeks 26^(0/7)-28^(6/7) weeks 35^(0/7)-37^(6/7) weeks Group 2 (n = 15) 11^(0/7)-13^(6/7) weeks 18^(0/7)-21^(6/7) weeks 29^(0/7)-31^(6/7) weeks 35^(0/7)-37^(6/7) weeks Group 3 (n = 15) 11^(0/7)-13^(6/7) weeks 22^(0/7)-25^(6/7) weeks 32^(0/7)-34^(6/7) weeks 35^(0/7)-37^(6/7) weeks

TABLE 6 Diagnostic Criteria for Preeclampsia with Severe Features and Inclusion/Exclusion Criteria Blood 1) Systolic BP ≥160 mmHG or diastolic BP ≥110 mmHg measured on at Pressure least 2 occasions 4 hours apart while on bedrest but before the onset of labor or measured on 1 occasion only, if antihypertensive therapy is initiated due to severe hypertension Measured by one of the following: Proteinuria 1) Excretion of ≥300 mg of protein in a 24 hr period 2) Protein/creatinine value of at least 0.3 3) qualitative determination with urine dipstick of ≥1+ OR Blood Pressure 1) Systolic BP ≥140 mmHg or diastolic ≥90 mmHG With one of the 1) Thombocytopenia (<100,000 p1atelets/mL) following features 2) Impaired liver function 3) Newly developed renal insufficiency 4) Pulmonary edema 5) New onset cerebral disturbances or scotomata Preeclampsia Cohort Inclusion Criteria Exclusion Criteria 1. Women 18 years of age or older 1. Known Malignancy 2. Pregnant women with a viable singleton 2. History of maternal organ or bone marrow gestation transp1ant 3. Gestational age between 20 0/7 and 33 3. Maternal blood transfusion in the last 8 6/7 weeks determined by ultrasound weeks and/or LMP per ACOG guidelines. 4. Chronic Hypertension diagnosed prior to 4. Preeclampsia diagnosed with severe current pregnancy features per ACOG guidelines 5. Type I, II or gestational diabetes 6. Fetal anomaly or known chromosome abnonnality 7. Active Labor Control Cohort Inclusion Criteria Exclusion Criteria 1. Women 18 years of age or older 1. Known Malignancy 2. Pregnant women with a viable singleton 2. History of maternal organ or bone marrow gestation transp1ant 3. Gestational age between 20 0/7 and 33 3. Maternal blood transfusion in the last 8 6/7 weeks determined by ultrasound weeks and/or LMP per ACOG guidelines. 4. Chronic Hypertension diagnosed prior to current pregnancy 5. Type I, II or gestational diabetes 6. Fetal anomaly or known chromosome abnormality 7. Active Labor 8. Thrombocytopenia (<100,000 plts/mL) 9. Impaired liver function 10. Newly developed renal insufficiency (serum creatine >1.1 mg/dL) 11. Pulmonary edema 12. New Onset cerebral disturbances or scotomata 13. Preeclampsia in prior or current pregnancy 14. Fetal growth restriction

TABLE 7 Study characteristics for Illumina Preeclampsia Cohort Early Onset PE Cohort Control Cohort Sample Size n = 40 n = 73 Gestational Age at Sample 30.5 (+/−2.6) 30.5 (+/−2.6) Collection (weeks · days) Maternal Characteristics Ethnicity (% Hispanic) 35% (n = 14) 41.1% (n = 30) Race % Caucasian 35% (n = 14) 46.6% (n = 34) % African 27.5% (n = 11) 17.8% (n = 13) American % Asian 7.5% (n = 3) 13.7% (n = 10) % Unknown 30% (n = 12) 20.5% (n = 15) % Other 0.0% 1.4% (n = 1) Maternal Age (years, mean +/− SD) 30.4 (+/−5.7) 29.7 (+/−5.3) Maternal BMI (kg/m2, mean +/− SD) 34.2 (+/−5.8) 30.1 (+/−5.6) Gravida (% Nulliparous) 32.5% (n = 13) 38.4% (n = 28) Chronic Hypertension 0% (n = 0) 0% (n = 0) Type I, II Diabetes 0% (n = 0) 0% (n = 0) Gestational Diabetes 0% (n = 0) 0% (n = 0) Birth Outcomes Gestational Age at Birth (weeks · days) 31.5 (+/−3.1) 38.9 (+/−1.8) Full Term 2.5% (n = 1) 90.4% (n = 66) Preterm (<37 weeks) 97.5% (n = 39) 9.6% (n = 7) Sex (% male) 37.5% (n = 15) 42.5% (n = 31) Birth Weight (kg) 1.4 (+/−0.52) 3.2 (+/−0.55) Small for Gestational Age* 45% (n = 18) 9.6% (n = 7) Stillbirth 2.5% (n = 1) 0% (n = 0) Medications for treatment of: PE/Hypertension MgSO4 82.5% (n = 33) 4.1% (n = 3) Antenatal Steroids 95.0% (n = 38) 6.8% (n = 5) Anti-Hypertensive 75.0% (n = 30) 5.3% (n = 4) Aspirin 20.0% (n = 8) 0% (n = 0) Other Conditions Analgesics 60.0% (n = 24) 11.8% (n = 9) Antimicrobials 12.5% (n = 5) 5.5% (n = 4) Antihistamines 32.5% (n = 13) 13.7% (n = 10) Asthma 10.0% (n = 4) 2.7% (n = 2) Psychoactive 15.0% (n = 6) 5.5% (n = 4) Hypothyroidism 7.5% (n = 3) 2.7% (n = 2) Antiemetics 25.0% (n = 10) 5.5% (n = 4) Pregnancy Antacids 27.5% (n = 11) 8.2% (n = 6) Symptoms Anti-constipation 15.0% (n = 6) 11.8% (n = 9) Prenatal Vitamins 17.5% (n = 7) 31.5% (n = 23) Iron Supplement 10% (n = 4) 12.3% (n = 9) *Defined as birthweight <10% of population for male or female fetus

TABLE 8 Medical Center Collection Site Patient Distribution Number PE Number of Clinical Site Location patients controls University of Texas Medical Branch Galveston, Texas 4 11 Tufts Medical Center Boston, MA 10 17 Columbia University Irving Medical New York, NY 4 9 Center Winthrop University Hospital Mineola, NY 5 9 St. Peter's University Hospital New Brunswick, NJ 3 6 Christiana Care Newark, DE 7 13 Rutgers University Robert Wood New Brunswick, NJ 5 8 Johnson Medical School New York Presbyterian/Queens New York, NY 2 3 Total Samples collected 40 76

TABLE 9 Genes validated by TaqMan qPCR Gene Name Assay ID Type RefSeq ABHD12 Hs01018050_m1 Reference NM_001042472.2 ABHD12 Hs01018050_m1 Target NM_001042472.2 ADAMTS2 Hs01029111_m1 Target NM_014244.4 ALOX15B Hs00153988_m1 Target NM_001039130.1 ARHGEF25 Hs00384780_g1 Target NM_001111270.2 ARRDC2 Hs01006434_g1 Target NM_001286826.1 CLEC4C Hs01092460_m1 Target NM_130441.2 DAAM2 Hs00322497_m1 Target NM_001201427.1 FAM107A Hs00200376_m1 Target NM_001076778.2 HSPA12B Hs00369554_m1 Target NM_001197327.1 HTRA4 Hs00538137_m1 Target NM_153692.3 IGFBP5 Hs00181213_m1 Target NM_000599.3 KRBOX4 Hs01063506_gH Reference NM_001129898.1 KRT5 Hs00361185_m1 Target NM_000424.3 LEP Hs00174877_m1 Target NM_000230.2 NES Hs00707120_s1 Target NM_006617.1 NME3 Hs01573872_g1 Reference NM_002513.2 PAPPA2 Hs01060983_m1 Target NM_020318.2 PITPNM3 Hs01107787_m1 Target NM_001165966.1 PLD4 Hs00975488_m1 Target NM_001308174.1 PRG2 Hs00794928_m1 Target NM_001243245.2 TIMP3 Hs00165949_m1 Target NM_000362.4 TIMP4 Hs00162784_m1 Target NM_003256.3 VSIG4 Hs00907325_m1 Target NM_001184830.1 WNT7A Hs00171699_m1 Reference NM_004625.3 ZEB1 Hs01566408_m1 Target NM_001128128.2 ZNF138 Hs00864088_gH Reference NM_001271638.1

TABLE 10 Previous Gene Literature Change Sub-Cellular Symbol Analysis Reports in PE Tissue Expression Category Location Function(s) ARRDC2 AdaBoost No Increase* Other (Skeletal Muscle; Membrane Protein Trafficking Globus Pallidus; Lung) ALOX15B DEX Yes Increase Fetal Nucleus; Cytoskeleton; Cell Cycle; Cytosol; Membrane Immune Function; Cardiovascular Function AMPH DEX No Increase Fetal Cytoskeleton; Synaptic Vesicle Endocytosis Membrane CUX2 DEX No Decrease Fetal Nucleus Cell Cycle; Fetal Development; DNA Damage Response FAM107A DEX No Increase Fetal Cytoskeleton; Cell Migration/Invasion; Membrane; Cell Cycle; ECM Regulation Nucleus IGFBP5 DEX Yes Increase Fetal Extracellular Fetal Development; IGF Signaling or Secreted NES DEX Yes Increase Fetal Cytoskeleton Fetal Development; Cell Cycle PITPNM3 DEX No Increase Fetal Membrane Phosphatidylinositol Regulation PRX DEX Yes Increase Fetal Membrane Cell Structure/Composition TEAD4 DEX Yes Increase Fetal Nucleus Placental Development PNMT DEX Yes Increase Other (Adrenal Cytosol Epinephrine Synthesis; Gland Cortex; Cardiovascular Function; Adrenal Gland; Pregnancy Duration Skeletal Muscle Psoas) DAAM2 DEX Yes Increase Other (Corpus Callosum; Extracellular Fetal Development Globus Pallidum External; or Secreted Nodose Nucleus) SLC9A3R2 DEX No Increase Other (Heart Ventricle; Membrane; Nucleus ECM Regulation; Liver; Parotid Gland) Cell Structure/Composition HSPA12B DEX No Increase Other (Heart Ventricle; unknown Angiogenesis; Cardiovascular Function; Lung; Spleen) Cell Migration/Invasion; Hypoxia Response PLD4 DEX No Decrease Other (Nodose Nucleus; Membrane Phosphatidylinositol Subthalamic Nucleus; Regulation; Immune Function Corpus Callosum) TIMP4 DEX No Increase Other (Omental Extracellular ECM Regulation; Immune Function Adipose Tissue; or Secreted Subcutaneous Adipose Tissue; Joint Synovium) KRT5 DEX Yes Decrease Other (Oral Mucosa; Cytoskeleton Cell Structure/Composition Pharyngeal Mucosa; Esophagus) ZEB1 DEX No Increase Other (Synovial Membrane; Nucleus Immune Function; Cell Migration/Invasion; Aorta; Myometrium) Fetal Development; Pregnancy Duration APOLD1 DEX Yes Increase Placental Plasma Membrane Angiogenesis; Cardiovascular Function; Hypoxia Response; Fetal Development HTRA4 DEX Yes Increase Placental Extracellular IGF Signaling; Placental Development or Secreted SEMA3G DEX No Increase Placental Extracellular Cell Migration/Invasion or Secreted ADAMTS1 DEX Yes Increase Placental/Fetal Extracellular ECM Regulation; or Secreted Fetal Development; Angiogenesis CRH DEX Yes Increase Placental/Fetal Extracellular Pregnancy Duration; or Secreted Fetal Development; Cardiovascular Function PRG2 DEX Yes Increase Placental/Fetal Extracellular Immune Function; or Secreted ECM Regulation; IGF Signaling TIMP3 DEX Yes Increase Placental/Fetal Extracellular ECM Regulation; or Secreted Immune Function; Angiogenesis ARHGEF25 DEX & No Increase Other (Hippocampus; Membrane; Sarcomere AdaBoost Myometrium; Cerebellum) CLEC4C DEX & Yes Decrease Other (Rectum Colon; Membrane Immune Function AdaBoost Ascending Colon; Substantia Nigra Reticulata) LEP DEX & Yes Increase Placental Extracellular Energy Homeostasis; AdaBoost or Secreted Immune Function; Angiogenesis; Fetal Development; ECM Regulation PAPPA2 DEX & Yes Increase Placental Extracellular Fetal Development; AdaBoost or Secreted IGF Signaling VSIG4 DEX & Yes Increase Placental Membrane Immune Function AdaBoost ADAMTS2 DEX & No Increase Placental/Fetal Extracellular ECM Regulation; AdaBoost or Secreted Angiogenesis; Fetal Development Key Increase* indicates the change was not statistically different CorrelationEngine Body Atlas was used to find the 3 top tissues expressing genes in the “Other” category UniProt was used to determine sub-cellular localization . . . as a note; I merged all “membrane” classifications to one category (so Plasma Membrane; ER Membrane; etc are not distinct)

TABLE 11 Study characteristics for Illumina Preeclampsia Cohort Early Onset Early Onset Late Onset Late Onset PE Control PE Control Sample Size n = 12 n = 12 n = 12 n = 12 Gestational Age at Sample 29.2 (+/−2.3) 29.3 (+/−2.3) 35.6 (+/−1.3) 35.9 (+/−0.8) Collection (weeks · days) Maternal Characteristics Ethnicity (% Hispanic) 0% (n = 0) 0% (n = 0) 0% (n = 0) 0% (n = 0) Race % Caucasian 91.7% (n = 11) 100% (n = 12) 100% (n = 12) 100% (n = 12) % African 8.3% (n = 1) 0% (n = 0) 0% (n = 0) 0% (n = 0) Maternal Age (years, mean +/− SD) 29.3 (+/−3.5) 30.1 (+/−3.8) 30.2 (+/−4.8) 29.4 (+/−3.2) Maternal BMI (kg/m2, mean +/− SD) 33.6 (+/−9.0) 28.5 (+/−7.0) 32.2 (+/−4.9) 27.9 (+/−4.5) Gravida (% Nulliparous) 60% (n = 6) 58.3% (n = 7) 75% (n = 9) 75% (n = 9) Chronic Hypertension 13.3% (n = 2) 8.3% (n = 1) 8.3% (n = 1) 0% (n = 0) Type I, II Diabetes 13.3% (n = 2) 0% (n = 0) 25.0% (n = 3) 0% (n = 0) Gestational Diabetes 13.3% (n = 2) 33.3% (n = 4) 8.3% (n = 1) 16.7% (n = 2) Other Health Condition 0% (n = 0) 8.3% (n = 1) 0% (n = 0) 0% (n = 0) Birth Outcomes Gestational Age at Birth (weeks · days) 30.3 (+/−3.4) 39.0 (+/−1.5) 37.0 (+/−1.4) 39.7 (+/−1.6) Full Term 0% (n = 0) 91.7% (n = 11) 75.0% (n = 9) 91.7% (n = 11) Preterm (<37 weeks) 100% (n = 12) 8.3% (n = 1) 25.0% (n = 3) 8.3% (n = 1) Sex (% male) 75% (n = 9) 58.3% (n = 7) 66.7% (n = 8) 58.3% (n = 7) Birth Weight (kg) 1.3 (+/−0.54) 3.2 (+/−0.40) 2.7 (+/−0.55) 3.4 (+/−0.54) Fetal Growth Restriction 50.0% (n = 6) 0% (n = 0) 8.3% (n = 1) 0% (n = 0) Small for Gestational Age* 25% (n = 3) 0% (n = 0) 33.3% (n = 4) 25% (n = 3) Stillbirth 0% (n = 0) 0% (n = 0) 0% (n = 0) 0% (n = 0) HELLP 25.0% (n = 3) 0% (n = 0) 0% (n = 0) 0% (n = 0) Medications for treatment of: PE/Hypertension MgSO4 83.3% (n = 10) 0% (n = 0) 33.3% (n = 4) 0% (n = 0) Antenatal Steroids 100% (n = 12) 0% (n = 0) 25.0% (n = 3) 0% (n = 0) Anti-Hypertensive 100% (n = 12) 8.3% (n = 1) 75% (n = 9) 0% (n = 0) Aspirin 8.3% (n = 1) 25.0% (n = 3) 25.0% (n = 3) 8.3% (n = 1) *Defined as birthweight <10% of population for male or female fetus

Example 7 Circulating Transcriptome Measurements from Maternal Blood Detect a Molecular Signature of Early-Onset Preeclampsia

Circulating RNA (C-RNA) is continually released into the bloodstream from tissues throughout the body, offering an opportunity to non-invasively monitor all aspects of pregnancy health from conception to birth. This example determines that C-RNA analysis can detect aberrations in patients diagnosed with preeclampsia (PE), a prevalent and potentially fatal pregnancy complication. As an initial examination, the circulating transcriptome from 40 pregnancies was sequenced at the time of severe, early-onset PE diagnosis along, with 73 gestational age-matched controls. 30 transcripts consistent with the biology of PE were altered, and likely represent placental, fetal, and maternal contributions to the disease. Further, machine learning identified a combination of C-RNA transcripts which robustly classified PE patients in two independent cohorts (85%-89% accuracy). The ability of C-RNA to reflect maternal, placental and fetal health holds great promise for improving the diagnosis and identification of at-risk pregnancies. In summary, the circulating transcriptome reflects biologically relevant changes in patients with early-onset severe preeclampsia and can be used to accurately classify patient status.

Preeclampsia (PE) is one of the most common and serious complications of pregnancy, affecting an estimated 4-5% of pregnancies worldwide (Abalos et al., 2013, Eur J Obstet Gynecol Reprod Biol; 170:1-7; and Ananth et al., 2013, BMJ; 347:f6564) and is associated with substantial maternal and perinatal morbidity and mortality (Kuklina et al., 2009, Obstet Gynecol; 113:1299; and Basso et al., 2006, AMA; 296:1357-1362). In the United States, the incidence of PE is increasing due to advanced maternal age and the increasing prevalence of comorbid conditions such as obesity (Spradley et al., 2015, Biomolecules; 5:3142-3176), costing the US healthcare system an estimated 2 billion dollars annually (Stevens et al., 2017, Am J Obstet Gynecol; 217:237-248.e16).

PE is diagnosed as new-onset hypertension accompanied by maternal end-organ damage occurring after 20 weeks' gestation (Hypertension in Pregnancy: Executive Summary, 2013, Obstet Gynecol; 122:1122; and Tranquilli et al., 2014, Pregnancy Hypertens; 4(2): 97-104). However, there is significant heterogeneity in the presentation and progression of PE, including timing of disease onset, symptom severity, clinical manifestations, and maternal and neonatal outcomes (Lisonkova and Joseph, 2013, Am J Obstet Gynecol; 209:544.e1-544.e12). PE is primarily delineated based on whether it manifests before (early-onset) or after (late-onset) 34 weeks and if it presents with severe features, such as sustained elevation in blood pressure ≥160/110 mmHg, neurological symptoms, and/or severe liver or kidney injury (American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy, 2013, Obstet Gynecol; 122:1122-1131).

The pathophysiology of early-onset PE is incompletely understood, but is thought to occur in two phases (Phipps et al., 2019, Nature Reviews Nephrology; 15:275). Early-onset PE originates with abnormal implantation and placentation in the first trimester, related to maternal immune dysfunction (Hiby et al., 2010, J Clin Invest; 120:4102-4110; Ratsep et al., 2015, Reproduction; 149:R91-R102; and Girardi, 2018, Semin Immunopathol; 40:103-111), incomplete cytotrophoblast differentiation (Zhou et al., 1997, J Clin Invest; 99:2152-2164), and/or oxidative stress at the maternal-placental interface (Burton and Jauniaux, 2011, Best Pract Res Clin Obstet Gynaecol; 25:287-299), resulting in incomplete remodeling of the maternal spiral arteries and failure to establish the definitive uteroplacental circulation (Lyall et al., 2013, Hypertension; 62:1046-1054). This leads to inadequate placental perfusion after 20 weeks' gestation. The resultant placental dysregulation triggers phase two, which manifests predominantly as maternal systemic vascular dysfunction with negative consequences for the fetus, including fetal growth restriction and iatrogenic preterm birth (Hecht et al., 2017, Hypertens Pregnancy; 36:259-268; Young et al., 2010, Annu Rev Pathol; 5:173-192; and Backes et al., 2011, J Pregnancy; 2011:doi:10.1155/2011/214365. In contrast, the placental dysfunction in late-onset PE is thought to be due not to abnormal placentation, but to disturbance in placental perfusion resulting from maternal vascular disease, such as that seen in patients with chronic hypertension, pregestational diabetes (Vambergue and Fajardy, 2011, World J Diabetes; 2:196-203), and collagen vascular disorders (“Placental pathology in maternal autoimmune diseases-new insights and clinical implications,” 2017, International Journal of Reproduction, Contraception, Obstetrics and Gynecology; 6:4090-4097).

The heterogeneity and complexity of this disease have made it difficult to diagnose, to predict risk, and to develop treatments. Further, the inability to easily interrogate the primary affected organ, the placenta, has limited molecular characterization of disease progression. Circulating RNA (C-RNA) has shown great promise for non-invasive monitoring of maternal, placental and fetal dynamics during pregnancy (Tsui et al., 2014, Clin Chem; 60:954-962; and Koh et al., 2014, Proc Natl Acad Sci USA; 111:7361-7366). C-RNA is released by many tissues into the bloodstream via multiple cellular processes of apoptosis, microvesicle shedding, and exosomal signaling (van Niel et al., 2018, Nat Rev Mot Cell Biol; 19:213-228). Due to these diverse origins, C-RNA measurements reflect tissue-specific changes in gene expression, intercellular signaling, as well as the degree of cell death occurring within different tissues throughout the body. Thus, C-RNA has the potential to elucidate the molecular underpinnings of PE and ultimately identify predictive, prognostic and diagnostic biomarkers of the disease (Hahn et al., 2011, Placenta; 32:S17-20).

Several studies have begun to investigate and identify potential C-RNA-based biomarkers for a range of pregnancy complications, including preterm birth, PE, and infectious disease (Pan et al., 2017, Clin Chem; 63:1695-1704; Ngo et al., 2019, Science; 360:1133-1136; and Whitehead et al., 2016, Prenat Diagn; 36:997-1008). However, the significant interindividual variability in this sample type threatens to obscure subtle changes in disease specific biomarkers (Meder et al. 2014, Clin Chem; 60:1200-1208). Therefore, many PE-focused C-RNA studies have measured RNA of previously identified serum protein biomarkers, including soluble FLT1, soluble endoglin, and oxidative stress and angiogenic markers (Nakamura et al., 2009, Prenat Diagn; 29:691-696; Purwosunu et al., 2009, Reprod Sci; 16:857-864; and Paiva et al., 2011, J Clin Endocrinol Metab; 96:E1807-1815). While protein measurements of these serum markers are known to be altered in PE (Maynard et al., 2003, J Clin Invest; 111:649-658; Venkatesha et al., 2006, Nat Med; 12:642-649; and Rana et al., 2018, Pregnancy Hypertens; 13:100-106), it is unknown whether they will serve as the most effective predictors in C-RNA, thus warranting a broader discovery approach.

In this example, global measurements of the circulating transcriptome detect unique molecular signatures specific to early-onset severe PE. To facilitate discovery, the performance of whole transcriptome enrichment for high throughput sequencing was optimized, allowing for measurement of >14,000 C-RNA transcripts per sample with high confidence. C-RNA profiles were then globally characterized from a preliminary cohort of 113 pregnancies, 40 of which were diagnosed with early-onset severe PE. All analysis methods were tailored to address the high biological variance inherent to C-RNA and identified altered transcripts concordant with PE biology that can classify across cohorts with high accuracy, highlighting that this sample type offers an avenue to developing robust tests for assessing preeclampsia.

Results

Establishing a reproducible whole-transcriptome workflow for C-RNA.

C-RNA is present in plasma in relatively low abundance, dominated by ribosomal (rRNA) and globin RNA, and is a mixture of fragmented and full-length transcripts (Crescitelli et al., 2013, J Extracell Vesicles; 2:doi:10.3402/jev.v2i0.20677), all of which can affect the efficiency of library preparation methods for next generation sequencing. Thus, workflow was optimized to minimize variability and maximize exonic C-RNA signal (FIG. 37A).

Highly abundant globin and rRNA does not inform biomarker discovery and must be removed. However, standard depletion methods such as Ribo-Zero (Illumina, Inc) or NEBNext rRNA Depletion (New England Biolabs) are not well suited for low starting amounts of RNA (Adiconis et al., 2013, Nat Methods; 10:623-629). While upfront depletion with these methods successfully removed unwanted ribosomal sequences from C-RNA (FIG. 37B, gray), sequencing libraries did not consistently exhibit an increase in exonic C-RNA signal (FIG. 37B, orange). Instead, samples varied in the proportion of reads mapping to a complex and variable population of non-human RNA sequences such as GB Virus C (FIG. 37B, pink) (Manso et al., 2017, Sci Rep; 7:doi:10.1038/s41598-017-02239-5; and Whittle et al., 2019, Front Microbiol; 9:doi:10.3389/fmicb.2018.03266). Additionally, removal of highly abundant rRNA and globin RNA results in extremely low RNA inputs which increases the failure rate of ligation-based library preparation methods. To avoid these problems, a whole-transcriptome enrichment approach was selected which generates a library from all C-RNA followed by probe-assisted enrichment targeting the whole human exome (FIG. 37A). This method consistently generated high quality sequencing libraries that were composed of >90% exonic C-RNA with minimal contaminating signal from transcripts of limited interest (FIG. 37B, orange).

There is significant interindividual variability in C-RNA plasma concentrations (FIG. 38A), which can vary by an order of magnitude (average 1.1 ng/mL plasma; SD 0.7; range <0.1-5 ng/mL plasma). To ensure reproducible results, the effects of plasma volume input on C-RNA data quality was evaluated. Using less than 2 mL plasma significantly increased the biological coefficient of variation and decreased library complexity (FIGS. 38B and 38C), leading to a decrease in sensitivity. Therefore, a 4 mL plasma input was selected to minimize noise, maximize confidence in data quality and to ensure successful data generation from all individuals regardless of C-RNA plasma concentrations.

To achieve consistent handling of all samples across diverse collection sites, all processing was centralized and required shipping of the collected blood samples to a single lab. This necessitated an assessment of the impact of overnight shipping on C-RNA data quality. Blood from nonpregnant and pregnant women (gestational age, GA, >28 weeks) was collected in four blood collection tubes (BCTs) and stored overnight at the manufacturer-indicated temperature prior to processing: BD Vacutainer K2EDTA (Beckton Dickinson; 4° C.), BD Vacutainer ACD-A (Beckton Dickinson, 4° C.), Cell-Free DNA BCT (Streck, Inc., RT), Cell-Free RNA BCT (Streck, Inc., RT). A set of samples collected in EDTA BCTs was processed at the clinic within 2 hours to provide a baseline. The C-RNA pregnancy signal in each sample was measured by summing the normalized abundance level of 155 transcripts identified as pregnancy markers in two prior C-RNA publications (Tsui et al., 2014, Clin Chem; 60:954-962; and Koh et al., 2014, Proc Natl Acad Sci USA; 111:7361-7366). After overnight storage, the C-RNA pregnancy signal was clearly detectable in pregnant samples despite a reduction in overall signal intensity as compared to immediate processing of the EDTA samples (FIGS. 39A and 39B). No major differences were observed between the different BCTs after overnight storage, indicating all are appropriate for C-RNA analysis. Cell-Free DNA BCTs (Streck, Inc) were selected for subsequent sample collections as this enables room temperature shipping. Furthermore, correlation of transcriptomic profiles in a time course experiment confirmed that there is no increase in technical variance after room temperature storage up to five days in these BCTs (FIG. 39C).

The complete workflow was validated by recapitulating previous work monitoring C-RNA dynamics in healthy pregnancies from first to third trimester. Using 152 samples collected serially from 41 healthy pregnancies (Pre-Eclampsia and Growth Restriction Longitudinal Study Control Cohort—PEARL CC; NCT02379832; Table 13), 156 significantly altered transcripts were identified, with the majority increasing in abundance as pregnancy progresses (FIG. 32A; Table 14). 51% of identified transcripts changed primarily during the first trimester, 6% in the 3^(rd) trimester, and 43% were differentially regulated throughout gestation (FIG. 40; Table 14). First trimester genes were enriched for placental steroidogenesis and regulation of trophoblast differentiation, while third trimester genes were involved in the onset of labor. Transcripts that increase throughout gestation are associated with tissue and organ development and morphogenesis (Chatuphonprasert et al., 2018, Front Pharmacol; 9:doi:10.3389/fphar.2018. 01027; Debieve et al., 2011, Mol Hum Reprod; 17:702-9; Grammatopoulos and Hillhouse, 1999, Lancet; 354:1546-1549; and Marshall e al., 2017, Reprod Sci; 24:342-354). The results from the PEARL CC were highly concordant with the literature, as 42% of the altered genes were identified in prior C-RNA studies (FIG. 32B) (Tsui et al., 2014, Clin Chem; 60:954-962; and Koh et al., 2014, Proc Natl Acad Sci USA; 111:7361-7366). Of the 91 transcripts identified only in this study, 64% are expressed by placental and/or fetal tissues (tissue specificity defined as >2 fold higher than median of all tissues in Body Atlas) (FIG. 32C and FIG. 17)(Kupershmidt et al., 2010, PLOS ONE; 5:e13066). The remaining genes are hypothesized to reflect maternal tissue responses to pregnancy (Table 14).

Clinical Study Design for Early-Onset Severe PE

After confirming this workflow robustly detects pregnancy-related C-RNA dynamics, changes in C-RNA associated with pregnancy complications were then identified. The workflow was applied to samples collected from two independent PE cohorts, the Illumina Preeclampsia Cohort (iPEC; NCT02808494) and the PEARL Preeclampsia Cohort (PEARL PEC; NCT02379832). The iPEC was used for biomarker identification while the PEARL PEC was used for independent confirmation of our findings. Importantly, all samples in both cohorts were collected in Streck Cell-Free DNA BCTs and libraries were generated in the same manner as discussed in the previous section.

The iPEC study focused on early-onset PE with severe features and excluded women diagnosed with additional health complications such as chronic hypertension or diabetes, to prevent additional heterogeneity from obscuring a consistent PE-associated C-RNA signal (Table 15). 113 samples were collected across 8 sites (Table 17), 40 at the time of early-onset PE diagnosis, and 73 controls that were gestational age-matched to within 1 week (FIG. 33A). Maternal characteristics, pregnancy outcomes, and medications were recorded throughout the study (Table 12 and Table 16). Fetal gender, maternal age, and nulliparity were not significantly different between the PE and control groups. In contrast, BMI was significantly higher in the PE cohort, (p value=0.0007) (O'Brien et al., 2003, Epidemiology; 14:368-374). All but one patient with PE gave birth prematurely, in contrast to 9.5% of controls, confirming that our diagnostic criteria identified individuals severely impacted by this disease (FIG. 33C).

The PEARL PEC samples were collected by an independent institution (CHU de Québec-Université Laval) and consisted of 12 early- and 12 late-onset PE pregnancies with equal numbers of gestational age-matched controls (FIG. 33B). Maternal characteristics, pregnancy outcomes, and medications in use were recorded throughout the study (Table 18). As in iPEC, 100% of early-onset patients delivered prematurely while 75% delivered at term in the late-onset cohort, confirming the differences in severity associated with early- and late-onset PE. Chronic hypertension, diabetes and other maternal health conditions were not grounds for exclusion, making this cohort more representative of the heterogeneity inherent to the pregnant population.

Identification of Transcripts Consistently Altered in Early-Onset PE

Standard differential expression analysis (Robinson et al., 2010, Bioinformatics; 26:139-140) using the full iPEC cohort identified 42 transcripts with altered abundance in plasma, 37 of which were increased in PE (FIG. 34A, blue and orange). However, variability in the differentially abundant transcripts was observed when different subsets of samples were selected for analysis. A jackknifing approach (Library, 1958, Ann Math Statist; 29:614-623) was therefore incorporated, enabling the identification of transcript abundances that are most consistently altered when comparing PE to control samples (FIGS. 34A and 34B, orange). One thousand iterations of differential analysis with randomly selected PE and control sample subsets were performed, resulting in the construction of confidence intervals for the p-values associated with each putatively altered transcript (FIG. 34C). Twelve transcripts whose p-value confidence interval exceeded 0.05 were subsequently excluded (FIG. 34B). These transcripts would not have been excluded by simply setting a threshold for baseline abundance or biological variance (FIG. 34D), however these transcripts were observed to have lower predictive value (FIG. 34E). Hierarchical clustering indicates these transcripts are not universally altered in the PE cohort, and thus lack sensitivity (73%) for accurate classification of this condition (FIG. 34F).

A representative set of 20 transcripts altered in PE were independently quantified by qPCR in a subset of affected and control iPEC patient samples. Fold changes measured by qPCR were highly concordant with the sequencing data, validating our findings (FIG. 35A and Table 19). 58% of the transcripts in the refined list have previously been associated with PE (Table 20). Additionally, nearly all genes can be linked to PE relevant processes, including extracellular matrix (ECM) remodeling, pregnancy duration, placental/fetal development, angiogenesis, and hypoxia response (Table 20). 67% of these genes were expressed by the placenta and/or fetus (FIG. 35B). In the remaining maternally expressed genes, cardiovascular and immune functions were well represented, both of which are altered in PE (Table 20) (Phipps et al., 2019, Nature Reviews Nephrology; 15:275).

Hierarchical clustering of these transcripts effectively segregated PE and control samples from iPEC with 98% sensitivity and 97% specificity (FIG. 35C). The refined list of 30 transcripts was validated with the independent PEARL PEC. Early-onset PE samples clustered separately from matched controls with 83% sensitivity and 92% specificity, further validating the relevance of these transcripts (FIG. 35D). In contrast, no clustering was observed for the late-onset PE and matched control samples indicating that late-onset PE has a potentially weaker or more likely a different C-RNA signature (FIG. 35E) (Redman, 2017, An International Journal of Women's Cardiovascular Health; 7:58; and Hahn et al., 2015, Expert Rev Mol Diagn; 15:617-629).

Upon closer inspection of the clinical data for the three misclustered iPEC samples, it was discovered that two controls suffered from potentially confounding health problems, including hypertension and in one case accompanied by preterm delivery. These controls should not have been enrolled in the iPEC due to our stringent exclusion criteria, thus they were excluded from further analyses. The misclustered PE sample showed no clinical abnormalities and was retained in our iPEC dataset.

Development of a Robust Machine Learning Classifier for Early-Onset PE

Differential expression analysis confirmed that C-RNA detects biologically relevant changes in PE patients. To assess if C-RNA signatures can robustly classify PE, the data from the iPEC cohort were used to build an AdaBoost model (Freund and Schapire, 1997, J Comp Sys Sci; 55:119-139; McPherson et al., 2011, PLoS Comput Biol; 7:doi:10.1371/journal.pcbi.1001138; and Lu et al., 2015, PLOS ONE; 10:e0130622). A randomly selected 10% of samples were excluded as a holdout set from the entire machine learning process to assess the final model performance. Then, a nested cross-validation approach was used for hyperparameter optimization (FIG. 42) and AdaBoost model building (FIG. 43) (Cawley and Talbot, 2010, J Machine Learning Res; 11:2079-2107).

While developing the machine learning approach, a high degree of variability was observed in AdaBoost performance and in the genes selected depending on which samples were included in training (FIG. 44). These observations indicate that different subsets of samples significantly impact model construction (Assessing and improving the stability of chemometric models in small sample size situations | SpringerLink (available on the world wide web at link.springer.com/article/10.1007%2Fs00216-007-1818-6)) which is likely due in part to the heterogeneity of PE. To account for this diversity, AdaBoost models were fit to multiple combinations of the training samples. The estimators from these orthogonally generated models were then combined into a single aggregate and pruned to obtain a minimal gene set (FIG. 43) (Martinez-Munoz and Suarez, 2007, Pattern Recognition Letters; 28:156-165; and AveBoost2: Boosting for Noisy Data | SpringerLink ((available on the world wide web at link.springer.com/chapter/10.1007/978-3-540-25966-4_3))). This allowed the capture of wide diversity of PE manifestations in a refined machine learning model with the potential to accurately classify independent samples from a broad pregnancy population.

Within each fold of the cross-validation, a threshold AdaBoost score was identified for discriminating PE and control samples which maximized both sensitivity and specificity. Across all ten folds, we obtained an average ROC of 0.964 (+/−0.068 SD) (FIG. 36A). Performance was first assessed in the holdout iPEC samples obtaining 89% (+/−5% SD) accuracy, with 88% (+/−13% SD) sensitivity and 92% (+/−6% SD) specificity (FIG. 36B, blue). AdaBoost classification performance was not affected by the amount of time prior to plasma processing, further supporting the robustness of our sample preparation protocol and analyses (FIGS. 40D and 40E). The model's capabilities to classify the independent PEARL PEC cohort were subsequently investigated. Early-onset PEARL PEC samples achieved 85% (+/−4% SD) accuracy, with 77% (+/−9% SD) sensitivity and 92% (+/−7% SD) specificity (FIG. 36B, pink). Unexpectedly, late-onset PEARL PEC samples were also classified with a reasonable accuracy of 72% (+/−6% SD), sensitivity of 59% (+/−10% SD) and specificity of 80% (+/−10% SD) (FIG. 36B, green).

49 total transcripts were used by AdaBoost, with 63% selected in at least 2 rounds of model building (FIG. 36C). Concordance was observed with prior analyses, as 40% of the genes identified in the jackknifing analysis were also used in machine learning (FIG. 36D, Table 21). 38% of the transcripts used by the classifiers have elevated expression in the placenta and/or fetus (FIG. 36E). Transcripts reflecting a diversity of PE-relevant pathways were observed, particularly genes associated with immune regulation and fetal development (Table 21).

Discussion

Whole transcriptome C-RNA analysis casts the wide net necessary for effective biomarker discovery, capturing a molecular snapshot of the diverse and complex interactions of pregnancy at a single point in time. Workflow and analyses were tailored to minimize technical noise, obtain high quality C-RNA measurements, and ultimately detect biologically relevant alterations. Importantly, molecular changes were detected specific to the complex pathophysiology of early-onset severe PE at the time of diagnosis, supporting robust classification across cohorts. The altered C-RNA transcripts identified represent contributions from maternal, placental and fetal tissues, many of which would not be captured in studies focusing on placental tissues collected after delivery. These discoveries highlight the power of C-RNA to comprehensively monitor signals contributed by diverse tissues of origin while the pregnancy is ongoing.

To identify the best method capable of detecting global and potentially subtle changes in pregnancy, the effects of plasma input, library preparation methods, and BCTs on C-RNA data quality were determined. As the majority of transcripts appear to be present in plasma at low abundance, the use 4 mL plasma inputs was chosen in protocols to minimize noise due to sampling error and poor library conversion, both of which plague low input sequencing applications. Upfront depletion of abundant RNA did not eliminate all contaminating RNA species, which were numerous and diverse in our sample population. This made targeted depletion infeasible, thus we selected a whole transcriptome enrichment approach to consistently isolate the exonic C-RNA signal of interest. Overnight shipping was a logistical requirement of the protocol, but runs the risk of introducing both signal loss due to C-RNA degradation as well as contamination with additional RNA from cell lysis. Streck Cell Free DNA BCTs, which inhibit cell lysis at room temperature (Zhao et al., 2019, J Clin Lab Anal; 33:e22670), were selected. This BCT is not specifically designed for RNA stabilization, but little evidence of C-RNA degradation was observed after storage for several days. Previous studies have shown that C-RNA has sufficient endogenous protection from extracellular nucleases (Tsui et al., 2002, Clin Chem; 48:1647-1653) thus additional precautions to protect the RNA are unnecessary. Together, these optimizations identified a workflow that maximizes C-RNA transcriptomic signal and minimizes technical variability, as illustrated by the numerous biologically relevant alterations observed across healthy and PE pregnancies.

Analyses next focused our analyses on identifying differences in circulating transcriptomes that are ubiquitous to the most extreme phenotype of the disorder, namely early-onset PE with severe features. This required tailoring our approach to account for the variability observed in our data that stems from both the substantial biological noise in C-RNA measurements as well as the phenotypic diversity of PE. C-RNA is inherently more variable than single tissue transcriptomics, because it interrogates RNA from diverse tissues and biological processes, not only detecting changes in gene expression but also differences in the rates of cell death and intercellular signaling. Furthermore, PE exhibits a wide range of maternal and fetal manifestations and outcomes, which may be associated with different underlying molecular causes and responses. While the genes eliminated after jackknifing may be biologically relevant in PE, they were not universally altered in the affected cohort. These transcripts may indicate a molecular subset of the disease and larger cohorts will help elucidate whether C-RNA can further delineate PE subtypes, which is crucial to understanding the diverse pathophysiology of this syndrome.

The transcripts identified by jackknifing represent a diversity of functions spanning the maternal-fetal interface. A majority of the identified changes relate to placental dysfunction and altered fetal development. One of the most striking trends was an increased abundance of ECM remodeling and cell migration proteins (N=10), tracking with dysfunctional extravillous trophoblast invasion characteristic of early-onset PE (Yang et al., 2019, Gene; 683:225-232; Zhu et al., 2012, Rev Obstet Gynecol; 5:e137-e143; and Wang et al., 2019, Scientific Reports; 9:2728). 20% of dysregulated genes identified encode for angiogenic proteins, consistent with a number of observations that the balance of angiogenic factors play a crucial role in regulating placental vascular development (Cerdeira et al., 2012, Cold Spring Harbor Perspectives in Medicine; 2:a006585-a006585) and can identify early-onset PE with severe features (Zeisler et al., 2016, N Engl J Med; 374:13-22). The data presented here indicated that fetal growth and development was also perturbed in early-onset severe PE, as evidenced by increased abundance of 4 transcripts encoding regulators of IGF signaling (Argente et al., 2017, EMBO Mol Med; 9:1338-1345; and Weyer and Glerup, 2011, Biol. Reprod; 84:1077-1086), a critical pathway for fetal development (Forbes and Westwood, 2008, Horm Res; 69(3):129-137). The remaining transcripts captured the maternal component of PE, namely immune and cardiovascular system dysregulation. Evidence of maternal immune imbalance, a hallmark of PE, appeared as altered abundance of immunological tolerance and pro- and anti-inflammatory factors (Chistiakov et al., 2014, Front Physiol; 5 (2014), doi:10.3389/fphys.2014.00279; Kumar et al., 2012, Cancers (Basel); 4:1252-1299; Qi et al., 2003, Nature Medicine; 9:407; and Yang et al., 2014, Biochim Biophys Acta; 1840:3483-3493). Transcripts important to blood pressure regulation as well as several genes linked to atherosclerosis were also identified as altered in PE C-RNA profiles, consistent with maternal vascular disease as an underlying mechanism predisposing some patients to PE (Calò et al., 2014, J Hypertens; 32:331-338; and Magnusson et al., 2012, PLOS ONE; 7:e43142). The transcripts identified captured a diversity of PE-relevant functions and highlights the ability of C-RNA to simultaneously monitor the numerous molecular processes implicated in complex disease.

Next, it was determined if C-RNA could not only detect biologically relevant changes but also accurately classify pregnancies affected by early-onset severe PE. The careful approach to AdaBoost model building described herein identified combinations of transcripts that can classify across distinct patient subsets, while excluding features that could lead to overfitting and bias in our model. Although 76% of transcripts used by AdaBoost were not identified as differentially abundant, they still reflect the same PE-relevant pathways that were captured in our jackknifing analysis. The success of this strategy was illustrated by the highly accurate classification of the independent early-onset PEARL PEC. These samples were collected at the time of diagnosis from a different population than the one used for training, with less stringent inclusion and exclusion criteria. For example, this cohort included 5 women who had chronic hypertension or gestational diabetes only 1 of which was misclassified by a few AdaBoost models, indicating the C-RNA changes utilized in machine learning were highly specific to PE.

This example provides an important step towards improved understanding and diagnosis of PE. The limited size of our clinical cohorts does not capture the phenotypic diversity of the global pregnant population and this is reflected in the lower values obtained for sensitivity than specificity in the classification analyses. Larger cohorts will better encompass the heterogeneity of PE, identifying signals for diverse manifestations of disease. A second limitation is the targeted nature of whole transcriptome enrichment and as such, does not capture the full range of non-coding or non-human transcripts present in plasma. Certain infections and miRNAs have been associated with PE (Nourollahpour Shiadeh et al., 2017, Infection; 45:589-600; and Skalis et al., 2019, Microrna; 8:28-35). Thus, future studies should aim to incorporate these measurements with C-RNA transcriptomic data. While the findings of this example are highly consistent with what is reported in the literature, alterations in transcripts of widely reported serum protein biomarkers such as soluble FLT1 (sFLT), vascular endothelial growth factor (VEGF) or placental growth factor (PIGF) were not observed (Phipps et al., 2019, Nature Reviews Nephrology; 15:275). This result is unsurprising given that gene expression is not always correlated with protein abundance or release into the circulation.

The iPEC sample collection was focused specifically on early-onset PE with severe features at the time of diagnosis. While this is the most extreme phenotype of the disease, it represents a small percent of PE cases and further in-depth exploration across the clinical PE spectrum is warranted. As a preliminary examination, the AdaBoost model was applied to the late-onset PEARL PEC cohort and achieved reasonably good accuracy (72%). This is surprising, given the substantial evidence that early- and late-onset PE are distinct conditions, despite sharing a final common phenotype of placental dysfunction (Burton et al., 2019, BMJ; 366:12381). Thus, some of the transcripts identified by AdaBoost likely reflect the response to uteroplacental insufficiency rather than its source and therefore may not have predictive value early in disease progression. In contrast, alterations in transcripts involved in angiogenesis and trophoblast invasion (Xie et al., 2018, Res Commun; 506:692-697; Hunkapiller et al., 2011, Development; 138:2987-2998; and Chrzanowska-Wodnicka, 2017, Curr Opin Hematol; 24; 248:255), known molecular drivers of PE initiation, were observed, and may have predictive value early in disease progression. Regardless of whether the changes detected represent cause or effect, or even a combination thereof, the methods and findings described herein show that C-RNA provides a unique opportunity to build robust diagnostic algorithms and investigate mechanisms of disease that were never considered before.

The successful classification of PE patients at the time of diagnosis showcases how C-RNA profiles can be used to robustly monitor maternal, fetal and placental functions in real-time. Future studies should focus earlier in pregnancy to evaluate the potential of this approach to improve prognostication and prediction of outcomes for women with PE. Indeed, such studies hold great promise for uncovering predictive biomarkers for early stratification of all at-risk pregnancies, informing prophylactic interventions or more vigilant monitoring of the pregnancy. The application of C-RNA will ultimately provide comprehensive molecular monitoring of maternal and fetal health throughout the course of pregnancy.

Materials and Methods Study Design

The objective of this example was to determine whether C-RNA can detect molecular markers associated with early onset PE with severe features. This goal was achieved by (i) optimizing a protocol to obtain robust whole transcriptome C-RNA measurements, (ii) analyzing blood plasma C-RNA profiles from patients at the time of PE diagnosis and gestationally age-matched control pregnancies, and (iii) validating our findings with C-RNA data generated from an independent cohort. The clinical protocol and informed consent forms for the iPEC study were approved by each clinical site's Institutional Review Board; inclusion and exclusion criteria are specified in Table 15. Investigators were blinded to sample status through the bioinformatic processing of sequencing data.

Clinical Sample Collection

iPEC. Pregnant patients were recruited in an Illumina sponsored clinical study protocol (NCT02808494) in compliance with the International Conference on Harmonization for Good Clinical Practice. Participants were recruited across 8 different clinical sites: University of Texas Medical Branch (Galveston, Tex.), Tufts Medical Center (Boston, Mass.), Columbia University Irving Medical Center (New York, N.Y.), Winthrop University Hospital (Mineola, N.Y.), St. Peter's University Hospital (New Brunswick, N.J.), Christiana Care (Newark, Del.), Rutgers University Robert Wood Johnson Medical School (New Brunswick, N.J.) and New York Presbyterian/Queens (New York, N.Y.).

After obtaining informed consent, 20 mL whole blood samples were collected from 40 singleton pregnancies with a diagnosis of PE before 34 weeks' gestation with severe features defined per ACOG guidelines (Table 15) (Hypertension in Pregnancy: Executive Summary, 2013, Obstet Gynecol; 122:1122). Samples from 76 healthy pregnancies were also collected and were matched for gestational age to the PE group. Three control samples developed term PE after blood collection and were excluded from the study. Maternal characteristics, birth outcomes (Table 32) and medications (Table 16) in use were all recorded during the study.

PEARL. Plasma samples from the PEARL study (NCT02379832) were used as an independent validation cohort. PEARL samples were collected at the Centre Hospitalier Universitaire de Québec (CHU de Québec). Only participants above 18 years of age were eligible, and all pregnancies were singleton. A group of 45 control pregnancies (PEARL Healthy Control Cohort; PEARL HCC) and 45 case pregnancies (PEARL Preeclampsia Cohort; PEARL PEC) were recruited in this study and written informed consent was obtained for all patients. A selection of plasma samples was obtained after the study had reached completion.

The criteria for PE was defined based on the Society of Obstetricians and Gynecologists of Canada (SOGC) June 2014 criteria for PE, with a gestational age requirement between 20 and 41 weeks, encompassing both early (diagnosed <34 weeks; N=12) and late onset (diagnosed >34 weeks, N=12) PE. A blood sample was taken once at the time of diagnosis from the PEARL PEC samples. The PEARL HCC included 45 pregnant women who were expected to have a normal pregnancy and were recruited between 11- and 13-weeks' gestation. Each enrolled patient was followed longitudinally with blood drawn at 4 timepoints throughout pregnancy until birth. The control women were divided into three subgroups and subsequent follow up blood draws were staggered to cover the entire range of gestational ages throughout pregnancy (Table 13). In addition to using the PEARL HCC samples to assess C-RNA in healthy pregnancy, samples from 24 unique individuals in the PEARL HCC were selected to serve as gestational age-matched controls for both the early- and late-onset PE cohort.

Sample Preparation

Plasma processing. All samples from the iPEC and the PEARL cohorts were processed in randomized batches by investigators blinded to disease status. Two tubes of blood were collected per patient in Cell-Free DNA BCT tubes (Streck, Inc.). Blood samples collected in iPEC were stored and shipped at room temperature overnight and processed within 120 hours. PEARL blood samples were collected, processed into plasma within 24 hours and stored at −80° C. until shipped to Illumina on dry ice. All blood was centrifuged at 1,600×g for 20 minutes at room temperature, plasma transferred to a new tube and centrifuged additional 10 minutes at 16,000×g. The plasma supernatant was stored at −80° C. until use.

Sequencing library preparation. C-RNA was extracted from 4.5 mL of plasma with the Circulating Nucleic Acid Kit (Qiagen) followed by DNAse I digestion (Thermo Fisher Scientific) according to manufacturer's instructions. C-RNA was fragmented at 94° C. for 8 minutes followed by random hexamer primed cDNA synthesis using the Illumina TruSight Tumor 170 Library Preparation kit (TST170; Illumina, Inc.). Illumina sequencing library preparation was carried out according to the TST170 kit for RNA, with two modifications: all reactions were reduced to 25% of original volume, and the ligation adaptor was used at a 1 in 10 dilution. Library quality was assessed with the High Sensitivity DNA Analysis chips on the Agilent Bioanalyzer 2100 (Agilent Technologies).

Whole-transcriptome enrichment. Sequencing libraries were quantified with Quant-iT PicoGreen dsDNA Kit (Thermo Fisher Scientific), normalized to 200 ng input and 4 samples pooled per enrichment reaction. The Illumina TruSeq RNA Enrichment kit (Illumina, Inc) was used to carry out whole exome enrichment. Briefly, biotinylated oligos targeting the exome were hybridized to sequencing libraries and pulled down by magnetic steptavidin beads to enrich libraries for exonic RNA. This process was performed two times to maximize exonic enrichment. Final enriched library was then re-amplified by PCR to provide sufficient yield for sequencing. Blocking oligos lacking the 5′ biotin designed against hemoglobin genes HBA1, HBA2, and HBB were included in the enrichment reaction to minimize contributions from highly abundant hemoglobin. Final enrichment libraries were quantified using Quant-IT Picogreen dsDNA Kit (Thermo Fisher Scientific), normalized and pooled for paired end 50 by 50 sequencing on Illumina HiSeq 2000 platforms to a minimum depth of 40 million reads per sample.

Sequencing Data Analysis

Bioinformatic processing of sequencing data. Fastq files containing over 50 million reads were downsampled to 50 million reads with seqtk (v1.2-r102-dirty). Sequencing reads were mapped to human reference genome (hg19) with TopHat2 (v2.0.13) (Yang et al., 2014, Biochim Biophys Acta; 1840:3483-3493), and transcript abundance quantified with featureCounts (subread-1.4.6) (Calò et al., 2014, J Hypertens; 32:331-338) against RefGene coordinates (obtained Oct. 27, 2014). Tissue expression data were obtained from Body Atlas (Correlation Engine, Base Space, Illumina, Inc) (Whittle et al., 2019, Front Microbiol; 9:doi:10.3389/fmicb.2018.03266). Genes with expression ≥2-fold higher than the median expression across all tissues in the placenta or any of the fetal tissues (brain, liver, lung, and thyroid) were assigned to that group. Subcellular localization was obtained from UniProt (Magnusson et al., 2012, PLOS ONE; 7:e43142). Functional enrichment analyses were performed with gProfiler (v e97 eg44_p13 d22abce) (Raudvere et al., 2019, Nucleic Acids Res; 47:W191-W198).

Differential expression analysis. Differential expression analysis was performed in R (v3.4.2) with edgeR (v3.20.9), after excluding genes with ≤0.5 counts per million reads sequenced (CPM) in >25% of samples. Datasets were normalized by the TMM method (Debieve et al., 2011, Mol Hum Reprod; 17:702-9), and differentially abundant genes identified by the glmTreat test (Shiadeh et al., 2017, Infection; 45:589-600) for a log fold change ≥1, followed by Bonferroni-Holm p-value correction. For the iPEC data, this same process was used for each jackknifing iteration, which used 90% of samples in each group selected by random sampling without replacement. After 1,000 jackknifing iterations, the one-sided, normal-based 95% confidence interval for gene-wise p-values was calculated with statsmodels (v0.8.0) (Skalis et al., 2019, Microrna; 8:28-35). The one-sided calculation was used because only transcripts with a p-value <0.05 were of interest. Hierarchical clustering analysis was performed with squared Euclidean distance and average linkage.

AdaBoost. AdaBoost was performed in python with scikit-learn (v0.19.1, sklearmensemble.AdaBoostClassifier) (Burton et al., 2019, BMJ; 366:12381). A 10% holdout subset of iPEC samples were excluded from all machine learning activities. The remaining samples available for training machine learning were filtered to remove genes with a CPM ≤0.5 in >25% of samples and TMM-normalized. The log(CPM) values of transcripts were then standardized (sklearn.preprocessing.StandardScaler) to mean 0 and standard deviation 1 prior to fitting classifiers.

Optimal hyperparameter values were determined by random search over 1,000 iterations with 3-fold stratified cross-validation and using Matthew's correlation coefficient to quantify performance (FIG. 42) (Bergstra et al., 2012, J Machine Learning Res; 13:281-305). The number of estimators was sampled from a geometric distribution (scipy.stats.geom, p=0.004, loc=7) while the learning rate was sampled from an exponential distribution (scipy.stats.expon, loc=0.08, scale=2). Three iterations of the search showed the highest performance, and the median value for each hyperparameter was selected for further use (500 estimators and 1.6 learning rate).

AdaBoost models were trained with 10-fold stratified cross-validation to obtain robust estimates of PE classification capabilities. The full AdaBoost model training strategy is illustrated in FIG. 43. This strategy followed a two-step approach. In the first step, five subsets of samples were created from the training data. Four subsets (80% of training data) were combined and used to fit AdaBoost and one subset (20% of the training data) was used to assess performance during feature pruning. During feature pruning, the performance measure was Matthew's correlation coefficient, and the model with the highest value was retained. In the case of a tie, the model with the fewest transcripts was retained. Due to the probabilistic nature of AdaBoost, model composition varied each time a model was fit. Therefore, to increase the likelihood that the most robust estimators were highly represented, fitting and feature pruning was repeated ten times, generating ten models for a subset. This process was repeated five times, in each round holding out one subset for pruning and combining the four others for fitting. This step ultimately produced 50 total models.

In the second step, the estimators from all 50 models were combined to generate a single aggregate AdaBoost model. This ensemble then underwent feature pruning, in which the importance measure for each transcript was the number of models in which it appeared, and the performance measure was log loss. The model with the best log-scaled average performance across all pruning subsets was selected as the final ensemble.

Within each fold, the validation samples were fully excluded from model training, but were used to construct ROC curves and determine the score threshold which maximized both sensitivity and specificity. The status of the iPEC holdout samples and the PEARL PEC independent cohorts were then classified with each of the 10 AdaBoost models from the cross-validation.

RT-qPCR

25 TaqMan probes (Table 19; Thermo Fisher Scientific) were selected to validate sequencing results in a subset of patients from the iPEC cohort (N=19 PE, N=19 controls). 5 reference probes were used for normalization of fold change differences. These targeted a set of transcripts unchanged between control and PE samples and covered a range of abundances from 0.2 to 20 CPM. Table S20 shows probes selected to span exon junctions.

C-RNA was isolated and converted to cDNA from 2 mL of plasma. cDNA was pre-amplified using the TaqMan Preamp master Mix (Thermo Fisher Scientific) for 16 cycles, then diluted 10-fold. Triplicate TaqMan qPCR reactions were carried out for all probes per the manufacturer's protocol (Thermo Fisher Scientific). Cq values were determined using Bio-Rad CFX manager software. To determine transcript abundance, the ΔΔCq was calculated using the mean Cq values of the reference probes. To determine the fold change in PE samples for each probe, the average ΔΔCq value for PE samples was divided by the average ΔΔCq value for the matched control samples.

Sample Preparation Protocol Optimization

rRNA and globin depletion. C-RNA was extracted from 2 mL plasma and DNAse treated prior to depletion. Use of the TruSeq Total RNA Library kit with RiboZero (Illumina, Inc.) followed the manufacturer's protocol. RNAseH depletion followed previously published protocols (Crescitelli et al., 2013, J Extracell Vesicles; 2:doi:10.3402/jev.v2i0.20677), except for hybridization which was performed in 6 uL total volume with a final concentration 125 pM/oligo for the depletion oligos.

C-RNA quantification. C-RNA was extracted from 4.5 mL plasma and DNAse treated. One tenth of the extracted C-RNA was used for quantification with the Quant-iT RiboGreen RNA Kit (Thermo Fisher Scientific). C-RNA was diluted 100-fold and quantified against the low range standard curve as recommended by the manufacture.

Plasma input comparison. Although no single experiment simultaneously assessed use of 0.5, 1, 2, and 4 mL plasma input, multiple datasets utilizing different plasma inputs were generated during protocol optimization. A meta-analysis was performed on the data from eight separate experiments to assess the impact of this variable. Biological coefficient of variation (BCV, edgeR) was used to quantify noise (Debieve et al., 2011, Mol Hum Reprod; 17:702-9). For every experiment, a BCV measurement was obtained for each set of samples composing a biologically distinct group. The bound population function from Preseq provided library complexity estimates (v2.0.0) (Xie et al., 2018, Res Commun; 506:692-697) for each individual sample. All sample preparation was performed as previously described with one exception: for 1 mL and 0.5 mL inputs, the Accel-NGS 1S Plus DNA Library Kit (Swift Biosciences) was used to generate libraries, following manufacturer instructions.

BCT comparison. 8 mL blood was drawn from pregnant and non-pregnant women in the following tube types: K2 EDTA (Beckton Dickinson), ACD (Beckton Dickinson), Cell Free RNA BCT tube (Streck), and Cell Free DNA BCT tube (Streck, Inc.). Blood was shipped overnight either on ice packs (EDTA and ACD) or at room temperature (Cell Free RNA and DNA BCT tubes). As a reference, 8 mL of blood was collected in K2 EDTA tubes and processed within 4 hours into plasma on site and shipped as plasma on dry ice. All other blood samples were processed after shipping after 1 or 5 days of storage at the preferred temperature. 3 mL of plasma was used per condition to generate sequencing libraries for enrichment using Illumina protocols as described previously. To compare pregnant and non-pregnant samples, pregnancy signal was quantified using 155 transcripts reported in prior C-RNA pregnancy studies (Tsui et al., 2014, Clin Chem; 60:954-962; and Koh et al., 2014, Proc Natl Acad Sci USA; 111:7361-7366) with the following equation:

$\sum\limits_{i = 1}^{155}\frac{x_{i} - m_{i}}{s_{i}}$

Where i denotes a single transcript, x is the log(CPM) value for the sample of interest, and m and s are the mean and standard deviation, respectively, for non-pregnant samples collected in the same BCT.

Pregnancy Timecourse analysis. Differential expression analysis was performed as described previously, without jackknifing. Transcripts altered during specific stages of gestation were identified as follows. The CPM values for each transcript were normalized within each patient using the first trimester sample (11-14 weeks gestational age) as baseline. The consensus values across all patients was obtained by Lowess smoothing (statsmodels.nonparametric.smoothers lowess.lowess). A transcript was classified as altered earlier in pregnancy if the slope of the Lowess curve was ≥2-fold higher in absolute magnitude at 14 weeks than at 34 weeks gestational age; transcripts were categorized as altered later in pregnancy if the slope of the Lowess curve was ≥2-fold higher in absolute magnitude at 34 weeks than at 14 weeks gestational age. The remaining transcripts were categorized as altered throughout pregnancy.

Statistical Analysis

Unless otherwise noted, all statistical testing was two-sided. Non-parametric testing was used when data were not normally distributed. P-values were adjusted for multiple comparisons via Bonferroni-Holm or Tukey HSD calculations.

TABLE 12 Study characteristics for the Illumina Preeclampsia Cohort (iPEC). Continuous measurements presented as mean +− SD. Sample and Maternal Characteristics Sample Sample Gestational Male Maternal Maternal Size Age Fetus Age BMI Nulliparous (N) (weeks) (%) (years) (kg/m²) (%) Control 73 30.5 ± 2.6 42.5 29.7 ± 5.3 30.1 ± 5.6 38.4 PE 40 30.4 ± 2.6 37.5 30.4 ± 5.7 34.2 ± 5.8 32.5 Ethnicity/Race African Hispanic Caucasian American Asian Other Unknown (%) (%) (%) (%) (%) (%) Control 41.1 46.6 17.8 13.7 1.4 20.5 PE 35 35 27.5 7.5 0 30 Birth Outcomes Birth Gestational Preterm Birth Age Delivery Stillbirth Weight SGA* (weeks) (%) (%) (kg) (%) Control 38.9 ± 1.8 9.6 0 3.2 ± 0.6 9.6 PE 31.5 ± 3.2 97.5 2.5 1.4 ± 0.5 45 *SGA, small for gestational age, defined as birthweight <10% of population for male or female neonate.

TABLE 13 PEARL HCC Gestational Age Distribution. 45 women with healthy pregnancies were divided into three groups and blood collected at 4 time points. Patient Number of Collection 1 Collection 2 Collection 3 Collection 4 Group Patients (weeks*) (weeks*) (weeks*) (weeks*) 1 14 11^(0/7)-13^(6/7 †) 14^(0/7)-17^(6/7) 26^(0/7)-28^(6/7 )  35^(0/7)-37^(6/7 †) 2 13 11^(0/7)-13^(6/7 †)   18^(0/7)-21^(6/7 †) 29^(0/7)-31^(6/7 †) 35^(0/7)-37^(6/7 ‡) 3 14 11^(0/7)-13^(6/7 §) 22^(0/7)-25^(6/7) 32^(0/7)-34^(6/7 †) 35^(0/7)-37^(6/7 †) *Indicated as a range from the minimum gestational age to the maximal gestational age, both in [weeks^(days/7)]. ^(†)1 sample failed library preparation ^(‡)2 samples failed library preparation ^(§)3 samples failed library preparation

TABLE 14 PEARL HCC pregnancy progression transcripts. Timing of Tissue Gene Fold Alteration in Expression Symbol Change* Pregnancy** Category ACOXL +27 Early Other ADAMI2 +5.9 Throughout Placental/Fetal AIM1L +8.1 Throughout Placental AKR1B15 +12.7 Throughout Other ALDH3B2 +26 Early Other ALPP +64.5 Early Placental/Fetal ANK3 +3.5 Early Placental/Fetal ANKFN1 +12.1 Throughout Placental ANKRD33 +9.1 Throughout Placental AOC1 +6.1 Throughout Other ATP6V1C2 +11.5 Early Placental BCAR4 +12.9 Throughout Placental C2orf72 +20.6 Throughout Placental/Fetal C4orf19 +8.9 Early Placental/Fetal CAMSAP3 +6.1 Late Fetal CAP2 +4.6 Throughout Other CAPN6 +26.4 Throughout Placental CDO1 +3.7 Throughout Placental/Fetal CFB +3.6 Early Placental/Fetal CGB5 −17.0 Early Other CGB8 −22.0 Early Other CRH +54.4 Late Placental/Fetal CRYAB +8.2 Early Other CSH1 +7.5 Throughout Placental/Fetal CSHL1 +48.4 Early Placental/Fetal CYP11A1 +14.5 Early Placental CYP19A1 +7 Throughout Placental/Fetal DACT2 +9.2 Throughout Placental DBET +9.9 Throughout Other DDX3Y +19.9 Early Other DEPDC1B +4 Early Placental/Fetal DLG5 +4.9 Throughout Placental/Fetal DLX3 +9 Late Placental DUSP4 +3.7 Throughout Placental/Fetal EFHD1 +6.7 Throughout Placental EFS +7 Throughout Placental EGFR +4.3 Throughout Placental/Fetal ELF3 +11 Early Fetal EPS8L1 +6.7 Throughout Placental/Fetal EPS8L2 +3.6 Throughout Placental ERVV-1 +8.5 Throughout Other ERVV-2 +7.5 Early Other ESRP2 +11.5 Throughout Other ESRRG +12.3 Early Placental EXPH5 +37.7 Throughout Placental FBN2 +5.6 Throughout Placental/Fetal FER1L6 +8.3 Late Other FOLR1 +7 Throughout Placental/Fetal FRZB +6 Early Placental FXYD3 +9.1 Early Placental/Fetal GADD45G +5.6 Throughout Placental GCM1 +5.7 Throughout Placental GDA +11.2 Early Placental/Fetal GLDN +8.2 Early Placental GOLGA8K −932.4 Throughout Other GPC3 +6.1 Throughout Fetal GRAMD2 +10.4 Throughout Placental GRB7 +11.6 Throughout Placental GRHL2 +26.8 Early Placental GRIP1 +4.3 Early Placental/Fetal GSTA3 +32.1 Early Placental HES2 +12.5 Early Placental HSD17B1 +9.5 Early Placental HSD3B1 +12.7 Early Placental HSPB8 +4.6 Early Placental IL36RN +9.9 Early Other KIAA1522 +3.2 Throughout Other KIF1A +18.7 Throughout Fetal KLF5 +3.4 Throughout Other KRT18 +3.9 Early Placental/Fetal KRT19 +4.2 Throughout Placental/Fetal KRT8 +4.4 Early Placental/Fetal KRT80 +10.3 Throughout Other KRT81 +13 Throughout Other LAD1 +8.6 Throughout Other LEP −46.2 Throughout Placental LGALS13 +7.7 Early Placental/Fetal LGALS14 +12.2 Early Placental LIN28B +7.2 Late Placental LINC00967 +22.5 Early Placental LINC01118 +6.4 Early Placental LY6G6C +11.2 Throughout Other MAGEA4 +10.4 Throughout Other MFSD2A +3.6 Throughout Placental MMP8 +4.8 Early Fetal MOCOS +5.1 Early Other MORN3 +4 Throughout Placental MSX2 +7.2 Throughout Placental MT1G −68.8 Early Fetal MUC15 +23.1 Early Placental NCCRP1 +5.7 Throughout Placental NCMAP +25 Early Other NRK +13.3 Early Placental OLAH +7.1 Early Placental OVOL1 +13.2 Throughout Fetal PACSIN3 +7.5 Throughout Other PAGE4 +1 1.5 Throughout Placental PAPPA +15.9 Early Placental PAPPA2 +7 Late Placental PCDH11X +7.3 Early Other PCDH11Y +20.3 Early Other PDZD2 +3.1 Throughout Placental/Fetal PGF +9.5 Early Placental PHYHIPL +12.5 Early Placental/Fetal PKIB +5.6 Early Placental PKP3 +10.5 Throughout Placental PLAC1 +32.7 Early Placental/Fetal PLAC4 +6.9 Early Placental PLEKHG6 +10.5 Throughout Other PLEKHH1 +5.2 Early Placental POU2F3 +10.9 Throughout Other PPP1R14C +10.9 Throughout Placental/Fetal PTPN3 +7.4 Early Other PVRL3 +4.1 Early Placental/Fetal PVRL4 +7.8 Throughout Placental RAB25 +7.8 Early Other RAB3B +43.7 Early Placental/Fetal RETN +4.1 Early Other RHOD +10.6 Early Placental/Fetal RLN2 −125.4 Late Other S100P +4.1 Early Placental/Fetal SCIN +7.1 Throughout Placental SEMA3B +4 Early Placental SERPINB2 +13.4 Early Placental SLC27A6 +10.1 Throughout Placental SLC28A1 +10.4 Late Fetal SLC30A2 +7.5 Throughout Placental SLC6A2 +6.4 Early Placental/Fetal SLC7A2 +6.2 Throughout Placental/Fetal SMOC2 +14.2 Throughout Other SPIRE2 +18.3 Early Placental/Fetal SPTLC3 +5.6 Throughout Placental STRA6 +7.5 Early Placental/Fetal SULT2B1 +35.4 Early Other SVEP1 +12.5 Early Placental TACC2 +36 Throughout Placental TBX20 +9.4 Early Other TEAD3 +9.5 Early Placental TFAP2A +17.9 Early Placental TFAP2C +9.4 Early Placental TGM2 +3.9 Throughout Placental/Fetal TMEM54 +11.2 Early Placental TNS4 +12.7 Throughout Placental TPPP3 +6.2 Throughout Placental/Fetal TPRXL +12.3 Early Placental TRIM29 +18.5 Early Placental TRPV6 +16.7 Early Placental TWIST1 +19.7 Throughout Placental USP43 +11.1 Early Placental UTY +18.6 Early Other VGLL1 +7.1 Early Placental/Fetal VGLL3 +13.6 Early Placental WWC1 +6.1 Early Fetal XAGE3 +11 Early Placental ZFY +16.3 Late Other ZNF750 +12.4 Early Placental *Reporting the maximal fold change observed between any pairwise comparison of age groups. All changes are relative to the lower GA group-positive change indicates increased abundance later in pregnancy. **If the slope of the log2(Fold Change) for a transcript is >2-fold higher at 14 weeks GA than at 34 weeks GA, it is considered altered early in pregnancy; if >2-fold higher at 34 weeks than at 14 weeks, it is considered altered late in pregnancy; if both fold changes are <2, it is considered altered throughout pregnancy.

TABLE 15 The iPEC diagnostic and inclusion/exclusion criteria for PE with severe features. Diagnostic Criteria Measurement Manifestation Blood Pressure 1. Systolic BP ≥160 mmHG or diastolic BP ≥160 mmHg measured on at least 2 occasions 4 hours apart while on bedrest but before the onset of labor, or measured on 1 occasion only if antihypertensive therapy is initiated due to severe hypertension Defined by one of the following: Proteinuria 1. Excretion of ≥300 mg of protein in a 24 hr period 2. Protein/creatinine value of at least 0.3 3. Qualitative determination with urine dipstick of ≥1+, if the above measurements were not available OR Blood Pressure 1. Systolic BP ≥140 mmHg or diastolic ≥90 mmHg on at least 2 occasions 4 hours apart while on bedrest but before the onset of labor With one of the 1. Thrombocytopenia (<100,000 platelets/mL) following features 2. Impaired liver function 3. Newly developed renal insufficiency 4. Pulmonary edema 5. New-onset cerebral disturbances or scotomata Inclusion/Exclusion Criteria Category Requirements PE Inclusion 1. Women 18 years of age or older 2. Pregnant women with a viable singleton gestation 3. Gestational age between 20 0/7 and 33 6/7 weeks determined by ultrasound and/or LMP per ACOG guidelines 4. Preeclampsia diagnosed with severe features per ACOG guidelines PE Exclusion 1. Known malignancy 2. History of maternal organ or bone marrow transplant 3. Maternal blood transfusion in the last 8 weeks 4. Chronic hypertension diagnosed prior to current pregnancy 5. Type I, II or gestational diabetes 6. Fetal anomaly or known chromosome abnormality Control Inclusion 1. Women 18 years of age or older 2. Pregnant women with a viable singleton gestation 3. Gestational age between 20 0/7 and 33 6/7 weeks determined by ultrasound and/or LMP per ACOG guidelines. Control Exclusion 1. Known malignancy 2. History of maternal organ or bone marrow transplant 3. Maternal blood transfusion in the last 8 weeks 4. Chronic hypertension diagnosed prior to current pregnancy 5. Type I, II or gestational diabetes 6. Fetal anomaly or known chromosome abnormality 7. Active labor 8. Thrombocytopenia (<100,000 plts/mL) 9. Impaired liver function 10. Newly developed renal insufficiency (serum creatine >1.1 mg/dL) 11. Pulmonary edema 12. New-onset cerebral disturbances or scotomata 13. Preeclampsia in prior or current pregnancy 14. Fetal growth restriction 15.

TABLE 16 Medications in use in the iPEC. Treatment PE Control Purpose Medication* Cohort (%) Cohort (%) PE/Hypertension Magnesium sulfate 82.5 4.1 Antenatal Steroids 95 6.8 Anti-Hypertensive 75 5.3 Aspirin 20 0 Pregnancy Symptoms Antiemetics 25 5.5 Antacids 27.5 8.2 Anti-constipation 15 11.8 Prenatal Vitamins 17.5 31.5 Iron Supplement 10 12.3 Other Conditions Analgesics 60 11.8 Antimicrobials 12.5 5.5 Antihistamines 32.5 13.7 Antiasthmatics 10 2.7 Psychoactive 15 5.5 Hormone Therapy 7.5 2.7 *Medication category listed for most drugs rather that enumerating all specific pharmaceuticals.

TABLE 17 Medical center collection site patient distribution for the iPEC. Location PE patients Controls Clinical Site (city, state) (N) (N) University of Texas Medical Branch Galveston, Texas 4 11 Tufts Medical Center Boston, MA 10 17 Columbia University Irving Medical Center New York, NY 4 9 Winthrop University Hospital Mineola, NY 5 9 St. Peter's University Hospital New Brunswick, NJ 3 6 Christiana Care Newark, DE 7 13 Rutgers University Robert Wood Johnson Medical New Brunswick, NJ 5 8 School New York Presbyterian/Queens New York, NY 2 3

TABLE 18 Study characteristics for PEARL PEC. Continuous measurements presented as mean +− SD. Sample and Maternal Characteristics Sample Sample Gestational Male Maternal Maternal Size Age Fetus Age BMI Nulliparous (N) (weeks) (%) (years) (kg/m²) (%) Early- 12 29.3 ± 2.3 58.3 30.1 ± 3.8 28.5 ± 7  58.3 Onset Control Early- 12 29.2 ± 2.3 75 29.3 ± 3.5 33.6 ± 9  60 Onset PE Late- 12 35.9 ± 0.8 58.3 29.4 ± 3.2 27.9 ± 4.5 75 Onset Control Late- 12 35.6 ± 1.3 66.7 30.2 ± 4.8 32.2 ± 4.9 75 Onset PE Ethnicity/Race African Hispanic Caucasian American Asian Other Unknown (%) (%) (%) (%) (%) (%) Early- 0 100 0 0 0 0 Onset Control Early- 0 91.7 8.3 0 0 0 Onset PE Late- 0 100 0 0 0 0 Onset Control Late- 0 100 0 0 0 0 Onset PE Birth Outcomes Birth Gestational Term Preterm Birth Age Delivery Delivery Stillbirth Weight SGA* (weeks) (%) (%) (%) (kg) (%) Early- 39.1 ± 1.5 91.7 8.3 0 3.2 ± 0.4 0 Onset Control Early- 30.3 ± 3.4 0 100 0 1.3 ± 0.5 25 Onset PE Late- 39.7 ± 1.6 91.7 8.3 0 3.4 ± 0.5 25 Onset Control Late-  37 ± 1.4 75 25 0 2.7 ± 0.6 33.3 Onset PE Additional Health Issues Chronic Type I, II Gestational Fetal Growth Hypertension Diabetes Diabetes Restriction HELLP Other Early- 8.3 0 33.3 0 0 8.3 Onset Control Early- 16.7 16.7 16.7 50 25 0 Onset PE Late- 0 0 16.7 0 0 0 Onset Control Late- 8.3 25 8.3 8.3 0 0 Onset PE PE/Hypertension Medications Magnesium Antenatal Anti- Sulfate Steroids Hypertensive Aspirin Early- 0 0 8.3 25 Onset Control Early- 83.3 100 100 8.3 Onset PE Late- 0 0 0 8.3 Onset Control Late- 33.3 25 75 25 Onset PE *SGA, small for gestational age, defined as birthweight <10% of population for male or female neonate.

TABLE 19 TaqMan Probes for qPCR validation. Gene Control CPM* PE CPM* Symbol Assay ID RefSeq (mean ± SD) (mean ± SD) Reference Probes ABHD12 Hs01018050_m1 NM_001042472.2 20.7 ± 6.5  20.5 ± 4.7  KRBOX4 Hs01063506_gH NM_001129898.1 5.1 ± 2  5.4 ± 1.8 NME3 Hs01573872_g1 NM_002513.2 1.6 ± 0.8 1.8 ± 0.8 WNT7A Hs00171699_m1 NM_004625.3  0.3 ± 0.03 0.3 ± 0.1 ZNF138 Hs00864088_gH NM_001271638.1 8.1 ± 3.3 7.5 ± 3.2 Target Probes ADAMTS2 Hs01029111_m1 NM_014244.4 0.6 ± 1.2 7.8 ± 7.5 ALOX15B Hs00153988_m1 NM_001039130.1 0.3 ± 0.3 1.9 +± .1  ARHGEF25 Hs00384780_g1 NM_001111270.2 1.3 ± 1  5.5 ± 2.6 CLEC4C Hs01092460_m1 NM_130441.2 4.3 ± 2.3 1.3 ± 0.9 DAAM2 Hs00322497_m1 NM_001201427.1 1.6 ± 1.8 9.6 ± 9.6 FAM107A Hs00200376_m1 NM_001076778.2 8.3 ± 5.5 44.2 ± 35.4 HSPA12B Hs00369554_m1 NM_001197327.1 5.9 ± 3.5 22.4 ± 11.7 HTRA4 Hs00538137_m1 NM_153692.3 0.4 ± 0.4 1.6 ± 1.2 IGFBP5 Hs00181213_m1 NM_000599.3 10.3 ± 5.8  39.9 ± 26.1 KRT5 Hs00361185_m1 NM_000424.3 3.1 ± 3.3 0.6 ± 0.7 LEP Hs00174877_m1 NM_000230.2 0.2 ± 0.5 1.8 ± 1.5 NES Hs00707120_s1 NM_006617.1 20.8 ± 12.5 101.6 ± 61   PAPPA2 Hs01060983_m1 NM_020318.2 5.9 ± 9.3 26.1 ± 16.6 PITPNM3 Hs01107787_m1 NM_001165966.1 22.6 ± 12.9 76.5 ± 43.6 PLD4 Hs00975488_m1 NM_001308174.1 5.5 ± 2.6  2 ± 1.3 PRG2 Hs00794928_m1 NM_001243245.2 0.6 ± 0.5 3.3 ± 5.6 TIMP3 Hs00165949_m1 NM_000362.4 3.7 ± 2.3 15.8 ± 10.7 TIMP4 Hs00162784_m1 NM_003256.3 0.4 ± 0.4  2 ± 1.9 VSIG4 Hs00907325_m1 NM_001184830.1 3.6 ± 3.8 30.9 ± 32.9 ZEB1 Hs01566408_m1 NM_001128128.2 245.9 ± 108.7 752.6 ± 434  *Calculated from the iPEC sequencing data

TABLE 20 Transcripts with C-RNA abundances altered in early-onset PE with severe features. Delineates the protein expression, functional characteristics, and PE-relevant literature of the genes identified by differential expression analysis with jackknifing (DEX) from the iPEC samples. Changes in PE PMID of Fold Manuscripts Gene Change Describing a Symbol Analysis in PE Role in PE ALOX15B DEX +5.7 22078795 AMPH DEX +5.0 NA CUX2 DEX & AdaBoost −3.3 NA FAM107A DEX +5.0 NA IGFBP5 DEX +3.6 28049695 NES DEX & AdaBoost +4.5 17653873 PITPNM3 DEX +3.2 NA PRX DEX +3.8 24657793 TEAD4 DEX & AdaBoost +3.3 NA PNMT DEX +3.8 NA DAAM2 DEX +5.6 20934677 SLC9A3R2 DEX +3.6 NA HSPA12B DEX +3.5 NA PLD4 DEX & AdaBoost −3.0 NA TIMP4 DEX +4.3 29231756 KRT5 DEX & AdaBoost −5.8 24657793 ZEB1 DEX +2.8 30315928 APOLD1 DEX +3.4 22013081 HTRA4 DEX +3.9 25946029 SEMA3G DEX & AdaBoost +3.5 NA ADAMTS1 DEX +3.5 29135310 CRH DEX +5.7 12709362 PRG2 DEX & AdaBoost +5.2 28347715 TIMP3 DEX +4.1 30715128 ARHGEF25 DEX & AdaBoost +4.1 NA CLEC4C DEX & AdaBoost −3.6 12699426 LEP DEX & AdaBoost +10.7 23544093 PAPPA2 DEX +4.9 26748159 VSIG4 DEX & AdaBoost +8.1 24349325 ADAMTS2 DEX & AdaBoost +11.6 NA Protein Characteristics Gene Tissue Sub-Cellular Symbol Expression Localization * Function ALOX15B Fetal Nucleus; Cell Cycle; Immune Function; Cytoskeleton; Cardiovascular Function Cytosol; AMPH Fetal Membrane Synaptic Vesicle Endocytosis Cytoskeleton; Membrane CUX2 Fetal Nucleus Cell Cycle; Fetal Development; DNA Damage Response FAM107A Fetal Cytoskeleton; Cell Migration/Invasion; Cell Membrane; Cycle; ECM Regulation Nucleus IGFBP5 Fetal Extracellular or Fetal Development; IGF Secreted Signaling NES Fetal Cytoskeleton Fetal Development; Cell Cycle PITPNM3 Fetal Membrane Phosphatidylinositol Regulation PRX Fetal Membrane Cell Structure/Composition TEAD4 Fetal Nucleus Placental Development Epinephrine Synthesis; PNMT Other Cytosol Cardiovascular Function; Pregnancy Duration DAAM2 Other Extracellular or Fetal Development Secreted SLC9A3R2 Other Membrane; ECM Regulation; Cell Nucleus Structure/Composition Angiogenesis; Cardiovascular HSPA12B Other unknown Function; Cell Migration/Invasion; Hypoxia Response PLD4 Other Membrane Phosphatidylinositol Regulation; Immune Function TIMP4 Other Extracellular or ECM Regulation; Immune Secreted Function KRT5 Other Cytoskeleton Cell Structure/Composition Immune Function; Cell ZEB1 Other Nucleus Migration/Invasion; Fetal Development; Pregnancy Duration APOLD1 Placental Plasma Angiogenesis; Cardiovascular Membrane Function; Hypoxia Response; Fetal Development HTRA4 Placental Extracellular or IGF Signaling; Placental Secreted Development SEMA3G Placental Extracellular or Cell Migration/Invasion Secreted ADAMTS1 Placental/Fetal Extracellular or ECM Regulation; Fetal Secreted Development; Angiogenesis CRH Placental/Fetal Extracellular or Pregnancy Duration; Fetal Secreted Development; Cardiovascular Function PRG2 Placental/Fetal Extracellular or Immune Function; ECM Secreted Regulation; IGF Signaling TIMP3 Placental/Fetal Extracellular or ECM Regulation; Immune Secreted Function; Angiogenesis ARHGEF25 Other Membrane; Cardiovascular function Sarcomere CLEC4C Other Membrane Immune Function LEP Placental Extracellular or Energy Homeostasis; Immune Secreted Function; Angiogenesis; Fetal Development; ECM Regulation PAPPA2 Placental Extracellular or Fetal Development; IGF Secreted Signaling VSIG4 Placental Membrane Immune Function ADAMTS2 Placental/Fetal Extracellular or ECM Regulation; Secreted Angiogenesis; Fetal Development * All “membrane” classifications were collapsed to a single category.

TABLE 21 Transcripts used by AdaBoost for classification of early-onset PE with severe features. Delineates the protein expression, functional characteristics, and PE-relevant literature of the genes identified with the iPEC model samples. Changes in PE PMID of Manuscripts Average Fold Describing Gene Number of Relative Change a Role Symbol Analysis Models Importance* in PE in PE ADA AdaBoost 3 0% −1.44 27939490 ADAMTS2 DEX & AdaBoost 6 18%  +11.57 NA AKAP2 AdaBoost 1 1% +1.95 NA ARHGEF25 DEX & AdaBoost 10 25%  +4.09 NA ARRB1 AdaBoost 1 19%  −1.17 30503206 ARRDC2 AdaBoost 8 7% +1.78 NA ATOH8 AdaBoost 5 2% +2.22 30301918 CLEC4C DEX & AdaBoost 8 8% −3.64 12699426 CPSF7 AdaBoost 1 1% +1.2 NA CUX2 DEX & AdaBoost 3 1% −3.3 NA FKBP5 AdaBoost 1 0% +2.8 26268791 FSTL3 AdaBoost 2 1% +2.57 30454705 GSTA3 AdaBoost 4 1% −2.54 28232601 HEG1 AdaBoost 3 3% +2.06 NA IGIP AdaBoost 4 1% +2.49 25802182 INO80C AdaBoost 2 2% −1.13 NA JAG1 AdaBoost 3 2% +2.13 21693515 JUN AdaBoost 6 3% +1.75 20800894 KRT5 DEX & AdaBoost 2 3% −5.78 24657793 LEP DEX & AdaBoost 9 8% +10.75 23544093 LILRA4 AdaBoost 4 2% −2.57 19368561 MRPS35 AdaBoost 1 0% −1.18 NA MSMP AdaBoost 7 9% +1.37 29059175 NES DEX & AdaBoost 6 9% +4.5 17653873 NFE2L1 AdaBoost 3 7% +2.39 26089598 NR4A2 AdaBoost 1 1% +1.42 18533121 NTRK2 AdaBoost 1 1% +2.67 21537405 PACSIN1 AdaBoost 1 1% −3.22 NA PER1 AdaBoost 3 5% +2.33 NA PLD4 DEX & AdaBoost 4 2% −3.03 NA PLEK AdaBoost 1 19%  −1.37 NA PRG2 DEX & AdaBoost 1 1% +5.24 28347715 RAP1GAP2 AdaBoost 6 2% −1.23 29643944 RGP1 AdaBoost 3 1% +1.26 NA SEMA3G DEX & AdaBoost 1 0% +3.48 NA SH3PXD2A AdaBoost 2 4% +2.36 23544093 SKIL AdaBoost 7 7% +1.46 20934677 SMPD3 AdaBoost 1 0% −2.3 23465879 SPEG AdaBoost 3 2% +1.87 NA SRPX AdaBoost 1 1% +2.89 20934677 SYNPO AdaBoost 1 1% +2.67 17255128 TEAD4 DEX & AdaBoost 3 5% +3.3 NA TIPARP AdaBoost 1 0% +1.28 28347715 TNFRSF21 AdaBoost 4 1% −1.52 NA TPST1 AdaBoost 1 0% +1.69 NA TRPS1 AdaBoost 1 0% +1.18 NA UBE2Q1 AdaBoost 1 50%  −1.1 NA VSIG4 DEX & AdaBoost 3 3% +8.13 24349325 ZNF768 AdaBoost 2 7% +1.6 NA Protein Characteristics Gene Tissue Sub-Cellular Symbol Expression Localization Function ADA Other Lysosome; Membrane Metabolism; Inflammation ADAMTS2 Placental/Fetal Extracellular or ECM regulation; Angiogenesis; Fetal Secreted Development AKAP2 Other Membrane Cardiovascular Function ARHGEF25 Other Membrane; Cardiovascular Function Sarcomere ARRB1 Other Cytosol GPCR Signaling; Cardiovascular Function; Immune Function ARRDC2 Other Membrane Protein Trafficking ATOH8 Other Nucleus Transcription Factor; Pregnancy Duration; Trophoblast Regulation CLEC4C Other Membrane Immune Function CPSF7 Other Nucleus; Cytoplasm mRNA Processing CUX2 Fetal Nucleus Cell Cycle; Fetal Development; DNA Damage Response FKBP5 Other Nucleus; Cytoplasm Immune Function; Steroid Hormone Receptor Trafficking FSTL3 Placental Extracellular or Fetal Development; Trophoblast Secreted; Nucleus Regulation GSTA3 Placental Cytoplasm Steroid Hormone Biosynthesis; Placental Development HEG1 Other Membrane; Fetal Development Extracellular or Secreted IGIP Other Extracellular or Cardiovascular Function Secreted INO80C Placental Nucleus Transcription Regulation; DNA Repair JAG1 Other Membrane Fetal Development; Angiogenesis; Trophoblast Regulation JUN Other Nucleus Transcription Factor; Trophoblast Regulation KRT5 Other Cytoskeleton Cell Structure/Composition LEP Placental Extracellular or Energy Homeostasis; Immune Function; Secreted Angiogenesis; Fetal Development; ECM Regulation LILRA4 Other Membrane Immune Function MRPS35 Other Mitochondria Energy Homeostasis; Cell Structure/Composition MSMP Other Extracellular or Angiogenesis Secreted NES Fetal Cytoskeleton Fetal Development; Cell Cycle Cardiovascular Function; Oxidative NFE2L1 Other Membrane; Nucleus Stress Response; Energy Homeostasis; Transcription Factor NR4A2 Other Nucleus; Cytoplasm Fetal Development; Steroid Hormone Response; Transcription Factor NTRK2 Fetal Membrane Trophoblast Regulation; Fetal Development PACSIN1 Fetal Membrane Cell Structure/Composition; Synaptic Vesicle Endocytosis PER1 Fetal Nucleus; Cytoplasm Circadian Rhythm PLD4 Other Membrane Phosphatidylinositol Regulation; Immune Function PLEK Fetal Cytosol Phosphatidylinositol Regulation; Immune Function; Cell Structure/Composition PRG2 Placental/Fetal Extracellular or Immune Function; ECM Regulation; IGF Secreted Signaling RAP1GAP2 Placental/Fetal Cytoplasm Immune Function; Angiogenesis; Fetal Development RGP1 Other Cytosol; Membrane Protein Trafficking SEMA3G Placenta Extracellular or Cell Migration/Invasion Secreted SH3PXD2A Other Cytoplasm ECM Regulation; Fetal Development SKIL Placenta Nucleus Transcription Factor; Placenta Development SMPD3 Fetal Membrane Lipid Metabolism SPEG Other Nucleus Fetal Development SRPX Other Extracellular or Angiogenesis Secreted SYNPO Placenta Cytskeleton; Cytosol Cell Structure/Composition TEAD4 Fetal Nucleus Placental Development TIPARP Other Nucleus Metabolism; Protein Processing TNFRSF21 Other Membrane Immune Function; Apoptosis TPST1 Other Membrane Protein Processing TRPS1 Other Nucleus Transcription Factor UBE2Q1 Other Nucleus; Cytosol Protein Processing VSIG4 Placenta Membrane Immune Function ZNF768 Other Nucleus Transcription Factor *Average for when included in an AdaBoost model.

The complete disclosure of all patents, patent applications, and publications, and electronically available material (including, for instance, nucleotide sequence submissions in, e.g., GenBank and RefSeq, and amino acid sequence submissions in, e.g., SwissProt, PIR, PRF, PDB, and translations from annotated coding regions in GenBank and RefSeq) cited herein are incorporated by reference in their entirety. Supplementary materials referenced in publications (such as supplementary tables, supplementary figures, supplementary materials and methods, and/or supplementary experimental data) are likewise incorporated by reference in their entirety. In the event that any inconsistency exists between the disclosure of the present application and the disclosure(s) of any document incorporated herein by reference, the disclosure of the present application shall govern. The foregoing detailed description and examples have been given for clarity of understanding only. No unnecessary limitations are to be understood therefrom. The disclosure is not limited to the exact details shown and described, for variations obvious to one skilled in the art will be included within the disclosure defined by the claims.

Unless otherwise indicated, all numbers expressing quantities of components, molecular weights, and so forth used in the specification and claims are to be understood as being modified in all instances by the term “about.” Accordingly, unless otherwise indicated to the contrary, the numerical parameters set forth in the specification and claims are approximations that may vary depending upon the desired properties sought to be obtained by the present disclosure. At the very least, and not as an attempt to limit the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques.

Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the disclosure are approximations, the numerical values set forth in the specific examples are reported as precisely as possible. All numerical values, however, inherently contain a range necessarily resulting from the standard deviation found in their respective testing measurements.

All headings are for the convenience of the reader and should not be used to limit the meaning of the text that follows the heading, unless so specified. 

What is claimed is:
 1. A method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method comprising: identifying in a biosample obtained from the pregnant women a plurality of circulating RNA (C-RNA) molecules; wherein a plurality of C-RNA molecules selected from: a plurality of C-RNA molecules encoding at least a portion of a protein selected from any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or a plurality of C-RNA molecules encoding at least a portion of a protein selected from any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or an increased risk for preeclampsia in the pregnant women.
 2. A method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method comprising: obtaining a biosample from the pregnant female; purifying a population of circulating RNA (C-RNA) molecules from the biosample; identifying protein coding sequences encoded by the C-RNA molecules within the purified population of C-RNA molecules; wherein the protein coding sequences encoded by the C-RNA molecules encoding at least a portion of a protein are selected from: any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or an increased risk for preeclampsia in the pregnant women.
 3. The method of claim 1, wherein identifying protein coding sequences encoded by C-RNA molecules within the biosample comprises hybridization, reverse transcriptase PCR, microarray chip analysis, or sequencing.
 4. The method of claim 1, wherein identifying protein coding sequences encoded by the C-RNA molecules within the biosample comprises sequencing.
 5. The method of claim 4, wherein sequencing comprises massively parallel sequencing of clonally amplified molecules.
 6. The method of claim 4, wherein sequencing comprises RNA sequencing.
 7. The method of claim 1, further comprising: removing intact cells from the biosample; treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA); synthesizing complementary DNA (cDNA) from C-RNA molecules in the biosample; and/or enriching the cDNA sequences for DNA sequences that encode proteins by exome enrichment; prior to identifying protein coding sequence encoded by the circulating RNA (C-RNA) molecules.
 8. A method of detecting preeclampsia and/or determining an increased risk for preeclampsia in a pregnant female, the method comprising: obtaining a biological sample from the pregnant female; removing intact cells from the biosample; treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA); synthesizing complementary DNA (cDNA) from RNA molecules in the biosample; enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment); sequencing the resulting enriched cDNA sequences; and identifying protein coding sequences encoded by enriched C-RNA molecules; wherein protein coding sequences encoded by the C-RNA molecules encoding at least a portion of a protein selected from: any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768 is indicative of preeclampsia and/or an increased risk for preeclampsia in the pregnant women.
 9. A method comprising: obtaining a biological sample from the pregnant female; removing intact cells from the biosample; treating the biosample with a deoxynuclease (DNase) to remove cell free DNA (cfDNA); synthesizing complementary DNA (cDNA) from RNA molecules in the biosample; enriching the cDNA sequences for DNA sequences that encode proteins (exome enrichment); sequencing the resulting enriched cDNA sequences; and identifying protein coding sequences encoded by the enriched C-RNA molecules; wherein the protein coding sequences encoded by the C-RNA molecules includes at least a portion of a protein are selected from: any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example 7; or any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768.
 10. The method of claim 1, wherein the biosample comprises plasma.
 11. The method of claim 1, wherein the biosample is obtained from a pregnant female at less than 16 weeks gestation or at less than 20 weeks gestation.
 12. The method of claim 1, wherein the biosample is obtained from a pregnant female at greater than 20 weeks gestation.
 13. A circulating RNA (C-RNA) signature for an elevated risk of preeclampsia, the C-RNA signature comprising any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve, any thirteen or more, any fourteen or more, any fifteen or more, any sixteen or more, any seventeen or more, any eighteen or more, any nineteen or more, any twenty or more, any twenty one or more, any twenty two or more, any twenty three or more, any twenty four or more, any twenty five or more, any twenty-six or more, any twenty-seven or more, any twenty-eight or more, any twenty-nine or more, any thirty or more, any thirty-one or more, any thirty-two or more, any thirty-three or more, any thirty-four or more, any thirty-five or more, any thirty-six or more, any thirty-seven or more, any thirty-eight or more, any thirty-nine or more, any forty or more, any forty-one or more, any forty-two or more, any forty-three or more, any forty-four or more, any forty-five or more, any forty-six or more, any forty-seven or more, any forty-eight or more, or all forth-nine of those listed in Table S9 of Example
 7. 14. The circulating RNA (C-RNA) signature for an elevated risk of preeclampsia of claim 13, the C-RNA signature comprising any one or more, any two or more, any three or more, any four or more, any five or more, any six or more, any seven or more, any eight or more, any nine or more, any ten or more, any eleven or more, any twelve or more, or all thirteen of AKAP2, ARRB1, CPSF7, INO80C, JAG1, MSMP, NR4A2, PLEK, RAP1GAP2, SPEG, TRPS1, UBE2Q1, and ZNF768.
 15. A solid support array comprising a plurality of agents capable of binding and/or identifying a C-RNA signature of claim
 13. 16. A kit comprising a plurality of probes capable of binding and/or identifying a C-RNA signature of claim
 13. 17. A kit comprising a plurality of primers for selectively amplifying a C-RNA signature of claim
 13. 18. The method of claim 1, wherein sample is a blood sample and the blood samples is collected, shipped, and/or stored in a tube that has cell- and DNA-stabilizing properties prior to processing the blood sample into plasma.
 19. The method of claim 18, wherein the tube comprises a Streck Cell-Free DNA BCT® blood collection tube. 